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PubMed2003

Lessons learned in phase I of the Southern Rural Access Program.

The Robert Wood Johnson Foundation's Southern Rural Access Program has been an important investment of philanthropic funds to augment resources and improve health care access in underserved rural communities. The program's first phase has taught important lessons about building capacity in rural health care. This article uses a variety of data to document the program's major accomplishments and most significant challenges to date. The program's revolving loan fund efforts are promising. The program has also played a catalytic role in stimulating rural health network development in the South and has helped stimulate partnerships with Southern philanthropies and multiple local, state, and federal agencies. Challenges have included the broad geographic and programmatic focus of the initiative as well as changing and often difficult state policy environments. Additional challenges include maintaining interagency coordination over time and managing staff and lead agency turnover. Overall, the experience suggests that a concentrated regional approach has merit.

Community Health Planning↗
PubMed2004

[Economic aspects of intensive care medicine--cost and reimbursement according to diagnosis related grouping].

We analyse relevant modifications of the new German diagnosis related reimbursement system for 2004. It is difficult to judge the consequences of financing intensive care systems by such flat rates. In our surgical ICU total treatment costs were 1 050.-euro /day and 11 530.-euro /patient. Comparison of our total costs and German federal calculation 2003 for long-term ventilation revealed that our costs resulting from a tertiary unit topped the average by 36-60 %. Already the present reimbursement was not cost rewarding. Evaluation according to the 2003 criteria resulted in profound further deterioration to a cost covering of only 49 %. The 2004 system, however, allows for better differentiation of patients and should result in improved reimbursement of long-term ventilation. Further professional analysis of the DRG system is essential for its "learning" development.

Cost Control↗
PubMed1996

Quality care for the seriously mentally ill: a dream deferred.

This is a study of a system in change-a public mental hospital, isolated by the strong Koolau mountains and neglected by its citizens. At the end of 1990, the federal Department of Justice jolted the people of Hawaii into recognizing the poor quality of care provided to their family members at the Hawaii State Hospital (HSH). This model of a recruitment and retention project was developed to address education, professional development, and recruitment needs of nursing staff at HSH to improve quality of care. The interventions were based on a dynamic model of collaboration between a public state hospital and a university school of nursing in the creation of a learning community. The components of the project provide for nursing staff to continue their formal university education, services of advanced practice nurses, and continuing education classes for nursing staff.

Hawaii↗
PubMed1999

Rationing care in the community: engaging citizens in health care decision making.

This article examines the theoretical and practical logics of community engagement exercises in health care rationing. To evaluate such exercises in Canada, it is necessary to compare suspected rationing exercises (such as those in Nova Scotia and Saskatchewan) with clear examples of rationing. The Oregon Medicaid reform process is considered an important example of transparent and community-level rationing from which Canadian executive-driven governments can learn a few valuable lessons. While the Oregon experiment seems to have been a (qualified) success, in the Canadian context, formal citizen participation in decision making might be incompatible with social rights and present an incongruous and antagonistic pairing of executive and popular sources of authority.

Community Participation↗
PubMed2001

Meeting psychological needs after Chernobyl: the Red Cross experience.

The explosion that took place in reactor number 4 of the Chernobyl Nuclear Power Plant on April 26, 1986 triggered the worst civilian nuclear disaster ever reported. Following requests for assistance by the Red Cross National Societies of Belarus, Ukraine, and Russia, the International Federation of Red Cross Societies set up the Chernobyl Humanitarian Assistance and Rehabilitation Program in 1990. Although the initial needs assessment mission mentioned psychological needs as an area of interest, it was not until 1997 that the first Psycho-Social Support pilot project started in Belarus. Objectives and strategy for the psycho-social support program are detailed, as well as the challenges currently faced by the program. The specific role of the media is also reviewed. Finally, the lessons learned from this experience are reviewed, and suggestions are made for future disaster planning.

Anxiety↗
PubMed2005

Involving the pharmaceutical and biotech communities in medication development for substance abuse.

Pharmacotherapy as adjunctive treatment is an integral part of the strategy for treating substance abuse. Although there are several approved drugs for the treatment of opioid, alcohol, and nicotine dependence, the pharmaceutical industry, for a variety of reasons, has been reluctant to enter this area to develop medications for substance abuse indications. Therefore, in 1990, a Medication Development Program was established by NIDA to carry out and assist in stimulating development of new pharmacotherapies. It is vital for NIDA to provide clear leadership and establish a collaborative working relationship with the pharmaceutical industry, providing scientific, development, and financial assistance, depending on the size, resources, and expertise of the company. An important NIDA role in this effort is setting standards, such as establishing Target Product Profiles (TPPs), predictive decision trees for selection of clinical candidates, and animal models to evaluate safety and potential effectiveness prior to human studies. NIDA can further establish standards for clinical studies, including Proof of Concept (PoC), Phase 2 (or Learning) trials to establish initial proof of safety and effectiveness, and Phase 3 (or Confirming) trials to validate Phase 2 findings. NIDA and other government agencies need to work to improve industry incentives to participate in medication development for substance abuse. Specific incentives, such as market exclusivity and patent extension, as provided in BioShield and pediatric drug legislation, should be strongly considered. NIDA can further assist industry to navigate the regulatory and, if needed, controlled substance scheduling processes, by establishing a true Federal partnership between NIDA, FDA, and DEA.

Animals↗
PubMed2003

Simulation-based medical education: an ethical imperative.

Medical training must at some point use live patients to hone the skills of health professionals. But there is also an obligation to provide optimal treatment and to ensure patients' safety and well-being. Balancing these two needs represents a fundamental ethical tension in medical education. Simulation-based learning can help mitigate this tension by developing health professionals' knowledge, skills, and attitudes while protecting patients from unnecessary risk. Simulation-based training has been institutionalized in other high-hazard professions, such as aviation, nuclear power, and the military, to maximize training safety and minimize risk. Health care has lagged behind in simulation applications for a number of reasons, including cost, lack of rigorous proof of effect, and resistance to change. Recently, the international patient safety movement and the U.S. federal policy agenda have created a receptive atmosphere for expanding the use of simulators in medical training, stressing the ethical imperative to "first do no harm" in the face of validated, large epidemiological studies describing unacceptable preventable injuries to patients as a result of medical management. Four themes provide a framework for an ethical analysis of simulation-based medical education: best standards of care and training, error management and patient safety, patient autonomy, and social justice and resource allocation. These themes are examined from the perspectives of patients, learners, educators, and society. The use of simulation wherever feasible conveys a critical educational and ethical message to all: patients are to be protected whenever possible and they are not commodities to be used as conveniences of training.

Computer Simulation↗
PubMed1997

The Federated Council of Internal Medicine's resource guide for residency education: an instrument for curricular change.

The Federated Council of Internal Medicine has developed a resource guide to help internal medicine residency programs produce internists who are prepared for today's practice of internal medicine and the challenges of practice in the future. The guide situates general internal medicine as the primary care profession that focuses on preventive, short-term, and long-term care of adult patients. It assumes that a single pathway is sufficient for educating general internists and subspecialty-bound trainees. It identifies the learning experiences that should be part of general internal medicine residency training, lists the clinical competencies that are important for primary care practice, and describes the role of the integrative disciplines that should inform the care of every patient. It also describes a process that program directors and local program committees can use to develop competency-based curricula.

Curriculum↗
PubMed1989

When violence has a benevolent face: the paradox of hunger in the world's wealthiest democracy.

During the last two decades, Americans initially discovered that millions of fellow-citizens were going hungry, then acted to virtually eliminate the problem, and, in the 1980s, learned that hunger has reappeared in epidemic proportions. Hunger, particularly in a wealthy democracy, is most appropriately seen as a form of institutionalized violence, the product of ideologies that fail to distribute national abundance in a manner that achieves the possible goal of preventing hunger. The return of hunger to the United States is associated with economic and tax policies that have reallocated income distribution from poor and middle-income groups to the wealthy, and with a concomitant reluctance to utilize the federal government to protect needy citizens from undernutrition associated with growing economic deprivation.

Adolescent↗
PubMedDate not supplied

Racial/ethnic disparities in the HIV and substance abuse epidemics: communities responding to the need.

In 1998, community leaders prompted members of the Black and Hispanic Congressional Caucuses to urge President Clinton to declare HIV/AIDS a crisis in the African American and Latino communities; their advocacy resulted in the formation of the Minority AIDS Initiative. As part of this initiative, the Center for Substance Abuse Prevention (CSAP) of the Substance Abuse and Mental Health Services Agency funded the Substance Abuse and HIV Prevention Youth and Women of Color Initiative (CSAP Initiative). The CSAP Initiative is the first major federal effort to develop community-based integrated HIV and substance abuse prevention approaches targeting racial/ethnic populations that have been disproportionately impacted by HIV/AIDS. This article describes the current state of HIV prevention research involving racial/ethnic minority populations and the current status of the CSAP Initiative. The data collected through the CSAP Initiative, implemented by 47 community organizations, will help to fill the existing knowledge gap about how to best prevent HIV in these communities. This data collection effort is an unparalleled opportunity to learn about risk and protective factors, including contextual factors, that are critical to the prevention of HIV/AIDS in African American, Latino, and other racial/ethnic minority communities but that are often not investigated.

Adolescent↗
PubMed2002

From anhydrobiosis to freeze-drying of eukaryotic cells.

Using what has been learned from nature, it has become possible to stabilize biological structures, including intact cells, in the dry state. Stabilization of cells or tissues in the dried state is of considerable practical significance, as is described in this review. The need for stabilization of cells in the dried state is particularly urgent in bloodbanks, where proper storage of blood cells (platelets and erythrocytes) is still a major problem. Human blood platelets are stored in blood banks for 5 days, after which they are discarded according to Federal regulation. This short lifetime has led to a chronic shortage of platelets. We report here that platelets can be preserved by freeze-drying them with trehalose, a sugar found at high concentrations in organisms that naturally survive drying. We suggest that this finding will obviate the storage problem with platelets and that the principles established here may be extended to more complex eukaryotic cells.

Blood Platelets↗
PubMed1999

Achieving high-quality health care and access for all.

In summary, lessons learned from past efforts point the way for the success of future initiatives. There continues to be a pronounced lack of URM applicants who gain entry into the nation's health professions schools. This shortfall may be attributed in part to inadequate academic preparation, and to a lack of awareness of health care careers and knowledge of financial aid resources. Communities and institutions have established model programs to address the problem of poor academic preparation. To this end, there is considerable understanding and commitment by federal, state, and local governments, which are now focusing their resources on the training and education of students in the early stages of the educational pipeline. The private sector also has recognized the importance of the changing demographics of the workforce and how it impacts the national economy. Therefore, the private sector is aggressively investing resources in the training, education, and quality of health care provided for ethnic and racial minority groups. The solution is to work hand in hand to ensure ever-increasing numbers of competitive students from URM backgrounds in the overall applicant pool for medicine and other health professions.

Cultural Diversity↗
PubMed2006

Advocacy and coverage of needle exchange programs: results of a comparative study of harm reduction programs in Brazil, Bangladesh, Belarus, Ukraine, Russian Federation, and China.

To prevent or mitigate an AIDS epidemic among injecting drug users (IDUs), effective activities need to be implemented on a large enough scale to reach and assist sufficient numbers of drug users and thereby change their risk behaviors related to drug use and sex. Recent work by UNAIDS on "high coverage sites", adopting the above strategies, has shown that one of the key elements in achieving high coverage is ongoing and sophisticated advocacy. High coverage harm reduction sites were studied through literature search and site visits, including key informant interviews, review of service statistics, and data analysis, in order to document the steps that led to scaling up, the way coverage was defined in these sites, and the lessons learned from their efforts. Syringe-exchange programs can achieve high coverage of IDUs. Monitoring to determine regular reach (those who are in regular contact with harm reduction services) should be added to uniform data collection carried out by harm reduction programs. Advocacy is crucial to achieving high coverage.

Bangladesh↗
PubMed1989

Case-mix payment for nursing home care: lessons from Maryland.

Even before Medicare adopted case-based payments for hospitals, some state Medicaid programs employed case-mix payment systems for nursing home care. Their purpose was less to promote cost containment than to improve access to nursing homes for the most costly patients. This paper evaluates one such system, adopted by the state of Maryland in 1983 as part of an overall reimbursement reform. Using data on nursing home patient characteristics, costs, and staffing, as well as interviews with officials and various providers of care, the article shows that Maryland's system was successful in shifting nursing home service away from light-care and toward heavy-care patients. Furthermore, the shift occurred without inducing readily measurable declines in quality of care and with little additional administrative cost (partly because the state built its case-mix system on preexisting patient review activities). Although states could learn from and improve upon Maryland's experience--most notably in offering incentives to improve quality of care and in targeting community care on the light-care patients that nursing homes become less willing to serve--Maryland demonstrates that case-mix payment can change nursing home behavior in desired directions without substantial negative consequences.

Activities of Daily Living↗
PubMed2002

Residents' prescription writing for nonpatients.

CONTEXT: Writing prescriptions is one of the most tangible new responsibilities that residents acquire after graduating from medical school. During their regular duties, house officers' prescription writing is carefully monitored. Little is known, however, about residents' patterns of prescription writing outside of supervision or about residents' knowledge of the ethical and legal guidelines that regulate prescription writing. OBJECTIVE: To study what factors influence residents' decision to write prescriptions for nonpatients. DESIGN, SETTING, AND PARTICIPANTS: Survey distributed in December 1997 to 92 internal medicine and family practice residents at a US community-based teaching hospital. Eighty percent responded. MAIN OUTCOME MEASURES: Self-reported prescribing activities for nonpatients and for individuals in 12 hypothetical vignettes. RESULTS: Eighty-five percent of respondents reported having written prescriptions for nonpatients. Based on their responses to the vignettes, under certain circumstances, up to 95% of residents would write a prescription for an individual who is not their patient (eg, a sibling). Thirteen percent of residents believed that some ethical guidelines on prescription-writing activity existed. Only 4% of residents reported being aware of federal or state laws addressing the appropriateness of physician prescription writing for nonpatients. None of the residents were able to describe the circumstances that make prescription writing for nonpatients illegal or unethical based on legal statutes or ethical guidelines, respectively. CONCLUSIONS: In a sample of community-based internal medicine and family practice residents, unsupervised prescription writing by residents for individuals who are not their patients is a common occurrence. Since residency training is a time when practice habits are established, it is important that all residents learn about the ethical, legal, and liability implications of writing prescriptions for nonpatients.

Data Collection↗
PubMed2002

The three R's: reciprocity, recertification and registry.

So what have we learned from all this? We have learned that "the three R's" need to be re-defined and reworked to make EMS a smoother-running profession. How do we, or how should we, go about making this change? In 1996, the National Highway Traffic Safety Administration (NHTSA) developed and published what has become known as "The Agenda," in which the authors suggested numerous ways to overcome certain situations in EMS. One situation in particular, and very relevant to the discussion, is the need for a National Office of EMS, or a federal lead EMS agency which is mandated by law. With the advent of the lead agency, each state has a sole agency, mandated by law, that adheres to national policy, but is still responsible for developing and overseeing its own statewide system. If we were to interpret the 10th and 14th Amendments, putting an "EMS spin" on them, we could say that the United States Constitution has granted each state the power to create EMS legislation. Accordingly, EMS certification and/or licensure is governed by each individual state. Having said that, each state does have its own office, but how many of those offices work together to make EMS, and particularly the "Three R's," standardized across the country? Another option is to contact your EMS-related service director, local or regional EMS council, state EMS office, and even your local or state political officers, and discuss these issues and potential solutions with them. Public opinion is a very strong tool, which, if used wisely, can alter the direction of certain issues.

Certification↗
PubMed1984

Use of sealants: societal and professional factors.

At present, sealant use continues at a low level in private practice by dentists and hygienists, and is moderate in community programs although there is high interest in their use in public health settings. Widespread delegation of sealant application to hygienists has not occurred even though the majority of state dental practice acts allow it, and even though practicing hygienists are highly interested in applying sealants. Use in federally sponsored programs is minimal or nonexistent. Information about sealants and adequate clinical experience in their application appear minimal in dental training institutions, and few opportunities have existed for continuing education. Generally, knowledge about sealants among dentists is low; many hold doubtful opinions. Insurance carriers, including commercial, provider, and governmental programs, appear reluctant to reimburse for sealants without purchaser demand and organized dentistry's blessings. Although society emphasizes patient rights to informed consent, few opportunities exist for the public, including group insurance purchasers and union negotiators, to learn about sealant use in conjunction with appropriate fluoride use. Public educational materials are sparse. Manufacturer marketing efforts at present, aimed at providers alone, are at best minimal, with a few exceptions; those targeting the public are nonexistent. Organized dentistry's Council statements may have contributed to a constriction, to date, in the flow of public information about sealants from industry. Lack of communication, or miscommunication, between practitioners and dental scientists has resulted in much misinformation and confusion about the value of sealants and their use. And, the contemporary status of dental manpower and the economy of dental practice in the private sector appear to have provided an infertile environment for acceptance of sealants as a primary preventive technology. In the public sector, interest in sealants is high but two primary constraints are inadequate manpower and lack of financial resources. Clearly there has been a time-lag in the adoption of new sealant products, and it is apparent that no one factor can explain this lag; rather, many complex factors must be taken into account simultaneously. Extent of need does not appear to have influenced use, to date. Often, social change is slow, and all things considered, the lag observed for sealants may not be totally unreasonable.(ABSTRACT TRUNCATED AT 250 WORDS)

American Dental Association↗
PubMed1995

From battered children to family violence: what lessons should we learn?

Child abuse is an ancient problem but one that has grown alarmingly in the United States in the last few decades. Once the problem of child abuse was recognized in the 1960s, mandatory reporting was instituted to develop public health mechanisms for intervention. But the approaches taken then were inadequate, and as sexual abuse of children was acknowledged, social service agencies gradually devolved from providing help to simply investigating, a trend that has contributed to the present emergency situation. Proper knowledge of how best to treat and prevent child abuse is scarce; this makes it harder to base an educational program in family violence on sound evidence. Also, public awareness of child abuse is far ahead of efforts to intervene and prevent it. Neither federal nor state laws have clear policies about what child protection strategies should be, which inhibits professionals who are attempting to deal with the problem. National guidelines and resources are needed, although efforts to solve the problem are best approached on a local level. Any teaching program on child abuse should discuss the policy alternatives, and any group that is helping children and their families must agree on a policy to guide its work. The author maintains that the child protection system should be run not by county or state governments but by the private and public health care system because this system has greater financial resources, has a tradition of scientific inquiry, and is still perceived as a "helping" system.(ABSTRACT TRUNCATED AT 250 WORDS)

Child↗