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PubMed2005

[Treatment for pulmonary arterial hypertension under the new French hospital financing system. Recommendations of the Pulmonary Vascular Diseases Working Group of the French Society of Pulmonary Medicine].

Activity-based financing (that is, casemix-based hospital payments, known as T2A) is intended to harmonize and improve the fairness of remuneration of public and private hospitals. T2A will ultimately rely mainly on a flat rate per admission, set according to the diagnosis-related group (DRG). Although payment for drugs is usually included in the DRG price, some expensive drugs will be reimbursed on an additional cost basis after implementation of a "best practices" agreement. Four drugs used for treatment of pulmonary arterial hypertension are eligible for this additional reimbursement: 3 prostacyclin derivatives (intravenous epoprostenol, inhaled iloprost, and subcutaneous treprostinil), and oral bosentan, an endothelin receptor antagonist. The Pulmonary Vascular Diseases working group of the French Society of Pulmonary Medicine has developed guidelines for the best practices in use of these drugs.

Antihypertensive Agents↗
PubMed2002

The relative cost of inpatient care in Manitoba's largest hospitals.

Comparative information from 1991/92 to 1997/98 regarding an indicator of the relative financial performance of teaching, urban community and major rural hospitals in Manitoba is presented. Results suggest that the acuity and complexity of patients in teaching and urban community hospitals was similar in 1997/98, and that teaching facilities had higher inpatient care costs in all time periods, even after accounting for differences in case-mix, physician remuneration, capital expenditures and the direct costs of teaching programs.

Benchmarking↗
PubMed2000

Critical care and perioperative medicine. How goes the flow?

The specialty of anesthesiology is at a crossroad. Do anesthesiologists stay in the illusionary safe harbor of the operating room and allow critical care anesthesiologists to float alone? How can in-fighting with other medical and nonmedical providers be avoided, while maintaining or expanding the historic and hopefully future roles of anesthesiologists as hospital-based physicians? A different tact is required to redefine the scope of the practice with broadened training to provide increased expertise in the evolving medical marketplace. This approach would include solid training in business, informatics, data management, and critical thinking on outcomes. This paradigm shift may be challenging, and requires redirection, reallocation of assets, re-education, and a new mindset. If successfully applied, however, it presents a means to strengthen the respected position of the specialty and to promote the medical care and practice of perioperative specialists in the rapidly changing landscape of modern medicine. Regarding the question of turf and ownership of the ICU, the authors suggest pursuing the higher ground of an excellent scope of practice, which facilitates the care and activities of surgical and primary care colleagues. These colleagues, administrators, and governmental agencies will have to be re-educated to support training and provide equitable remuneration. Appropriately trained anesthesiologist-intensivists can complement many other care providers, while providing a wide range of services with an economy of care, whether in a semiclosed or closed ICU setting.

Anesthesia Department, Hospital↗
PubMed1997

Altruism and payment in blood donation.

Paid blood donation still has its defenders, who cite economic doctrines denying the existence of altruism per se, the inability of most countries with exclusively voluntary donations to achieve self-sufficiency and the supposedly successful use of selected groups of paid donors. This paper argues that blood donation is an example of genuine altruism where the altruistic behaviour is incorporated into the self as a role. Unpaid donation is proven to be much safer for receivers and supply problems can be attributed fundamentally to inefficiencies in the organization of transfusion services. Voluntary and non-remunerated donation may be sufficient for a country/region to cover all its blood product needs, but requires an efficient organization and the elimination of "spurious altruism", nonmonetary forms of compensation that harm the social image of voluntary donation and obstruct its further development.

Altruism↗
PubMed1997

Planning for the future: advanced nursing practice in critical care.

The subject of advanced nursing practice has become a topic of great interest and considerable debate in recent years. It has as a concept, however, been increasingly obscured by the plethora of terms used to denote its particular role and function. The purpose of this paper is to suggest how a consensus may be achieved in terms of role clarification, educational preparation, intellectual skill, level of performance and remuneration. Fundamental elements of the current debate are seen to be the need for advanced nursing practice, how it will be recognized in practice, the parameters of the expanding role and the centrality of the patient rather than professional boundaries in delineating advanced nursing practice for critical care. The debate will no doubt continue. It is not the aim of this paper to reach a definitive understanding, but to provide a platform so that essential elements can be confronted and the development of the role carefully considered.

Clinical Competence↗
PubMed1999

A qualitative study of the Victorian critical care nurse labour force.

A perceived shortage of critical care nurses in Victorian public and private hospitals, largely attributed to an increase in attrition from critical care areas and a failure to attract sufficient replacement for those who leave, served as the impetus for this project, which explored registered nurses' (RNs') attraction to and attrition from critical care practice areas. Multiple sources of data were utilised, including a series of individual interviews and focus group discussions with critical care students and past and current critical care nurses, telephone interviews with RNs who had completed a critical care re-entry course, interviews with key informants and an analysis of applications to study in a critical care postgraduate nursing course. Results revealed that the challenge of the work, intellectual stimulation, the high level of autonomy, use of increased knowledge and career development were primary motivators for RNs to engage in critical care practice. Limitations to lifestyle choices, practice demands, political changes within critical care arenas, inappropriate remuneration and a lack of career structure and opportunity were salient features of why employment was discontinued within the critical care practice areas.

Attitude of Health Personnel↗
PubMed2003

[Clinical selection of blood donors].

For 20 years, the organization set up to insure the blood transfusion safety has never stopped strengthening. It is based on clinical and epidemiological selection of the blood donation candidates, biologic selection of blood donations and different physico-chemical techniques for pathogens reduction or inactivation in blood products. In France, this organization is optimized by the assertion of the voluntary and non-remunerated character of blood donation registered in the law of January 4th, 1993. The blood donors selection is structured in three successive stages. The first stage is the pre-donation information. The second stage begins with reading and filling out an info-questionnaire which prepare for an interview with a physician. This interview is specially directed to prevention of transfusion-transmitted infections and the prevention of adverse reactions after a 400 to 600 mL collection of whole blood or components. Finally, the third stage is the delivery of a post-donation information which invites the donor to contact the "établissement français du sang" (EFS) in case of a new event arisen after the donation or in case of reviewing of its own answers during the medical interview.

Blood Donors↗
PubMed1999

Career structures for South Australian nurses: developing a research agenda.

Career structure models are central to the organisation of the work of professionals like nurses, to their remuneration and other forms of recognition, and for the organisation of employing institutions. It has been little more than a decade since the implementation of a career structure model for nurses in South Australia in 1986-7. Since that time a number of changes to the profession, and to the health care system more generally, have resulted in ad hoc adaptations to, and sometimes an erosion of, the career structure as originally envisioned. As we approach the new millennium, an assessment and evaluation of the efficacy of the SA career structure in meeting the professional needs of nurses and their employing organisations is both timely and necessary. This paper provides the historical background to the development of the SA career structure, and highlights some of the major issues that have emerged as problematic since implementation. The paper then identifies some issues that might contribute towards guiding a more systematic approach to the re-appraisal of nurses' career structures.

Career Mobility↗
PubMed2006

Alternative solutions to the current situation of oocyte donation in Singapore.

The rising incidence of age-related female infertility in Singapore, coupled with the prohibition on commercialized oocyte donation and egg sharing, has resulted in a severe shortage of donor oocytes. Infertile women are routinely encouraged by fertility doctors here to seek their close relatives and friends as prospective oocyte donors, which does not alleviate the shortage. A number of alternative solutions are discussed. The use of substantial financial remuneration to encourage oocyte donation is rejected as being legally, ethically and morally incompatible with present day Singaporean society. Egg sharing in return for subsidized fertility may have a strong case for ethical justification, but implementation would need amendment of the current legislation in Singapore. Cross- and mirror-exchange oocyte donations face less of a legal challenge in Singapore and also have a strong case for ethical justification. However, special consideration must be given to the unique socio-cultural values of Singaporean society, i.e. traditional Chinese culture. Finally, if no changes are made to restrictive regulations governing oocyte donation in Singapore, and shortage of donor oocytes still persists, then reproductive tourism abroad may be the solution for some patients; referrals by local fertility doctors are unlikely to be allowed in Singapore.

Humans↗
PubMed2005

Decision making in general practice: the availability and use of a specific laboratory analysis.

OBJECTIVES: The aim of this investigation was to study the effect of general practitioners' (GP's) characteristics on two decisions: whether to have the Helicobacter pylori rapid test (HPRT) in the office laboratory and whether to use this test or a similar hospital-based serological test in a typical clinical situation described in a vignette. METHODS: Discrete choice analysis with binary logit models were used to predict the probability that a general practice has the HPRT, as well as the GP's probability of using the HPRT or a similar test in this clinical situation. RESULTS: We found that the number of consultations per week has a positive effect on the probability of having the HPRT, indicating that the size of the practice affects the decision to have such a test in the repertoire. Furthermore, four variables significantly increased the probability of using one of the lab tests: more if located in urban practices, more by solo practitioners, more when the GP stated a high probability for H. pylori associated disease, and more when the GP had the rapid test available in the practice. In our analysis, the remuneration system is endogenous and does not have a significant effect on the two decisions. CONCLUSIONS: Our study demonstrates that characteristics of the GP affect the availability and use of a specific laboratory analysis.

Decision Making↗
PubMed2000

Sexual consent: the criminal law in Europe and overseas.

What role can the criminal law play in the battle against child sexual abuse? Should sexual relations of and with, persons under a certain age be criminalized regardless of the circumstances, even if they are consensual ("age of consent," "minimum age")? Where should such a minimum age-limit be fixed? Should there be a special, higher age-limit for particular conditions (e.g., "seduction," "corruption")? Should sexual contacts with minors within a relationship of authority be criminalized generally, or just if authority is abused? Should criminal proceedings be instituted ex officio or upon complaint only? Should authorities be provided with a power of discretion or should they be obliged to prosecute and sentence in each case? In answering these questions, it is highly beneficial to have a look across the borders to the solutions other countries have reached. This study presents an overview on the criminal law governing the sexual behavior of, and with, children and adolescents in all European jurisdictions and in selected jurisdictions outside of Europe. It shows which categories of offences exist and from which age onward young people can effectively consent to various kinds of sexual behavior and relations in the different countries. All states in Europe and all of the studied jurisdictions overseas have minimum age limits for sexual relations, and punish sexual relations with persons under a certain age. Nowhere is this age set lower than 12 years. In Europe, in one-half of the jurisdictions, consensual sexual relations with 14-year-old adolescents are legal; in three-quarters, with 15-year olds; in a majority, this is also the case when the older partner has started the relation (and also when the initiative contains an offer of remuneration). In nearly all jurisdictions, such relations are legal from age 16 onward. Most states apply a higher age limit for contacts in relationships of authority. If the authority is not misused, the age limit in most jurisdictions is set between 14 and 16; if it is misused, between 16 and 18. Most states make no difference between heterosexual and homosexual relations.

Adolescent↗
PubMed2000

Professional autonomy in Belgium.

The Belgian health care system has a few features that may have contributed to the rising costs of health care: patients' free choice of physicians, large clinical freedom of physicians, essentially a fee-for-service remuneration for medical specialists in which the fees are agreed between insurance funds and physicians. The increased medical consumption and costs have prompted the state and insurance companies to take measures that limit the professional autonomy of the physicians. Access to medical education, free until 1997, is now restricted. The medical profession is organized in the Order of Physicians that has established a code of professional ethics that has moral but not legal force. So far, there is no special legislation for the patient-physician relationship, though laws on specitic issues like organ transplantation contain duties for physicians. In recent years a debate is taking place on patients' rights, of which informed consent is central and gaining importance in medico-legal publications. An analysis of (ethical and legal) regulations concerning the withholding or withdrawal of treatment by physicians demonstrate that the profession still enjoys a large clinical autonomy, though due discussion with the patient has become more explicitly required. The respect for professional autonomy is not primarily due to any formal power that the Order of Physicians would have, but is rather grounded in the generally high quality of the patient-physician relationship that in ethical terms is considered essentially as a confidence relationship rather than a contractual relationship.

Belgium↗
PubMed2001

The role of the community pharmacist in drug abuse: a comparison of service provision between Northern Ireland and England/Wales.

AIM: The aim of the present research was to establish the current extent of pharmacists' contact with illicit drug users in Northern Ireland, their willingness to provide services for this group and to compare the findings with data from a 1995 national survey of community pharmacies in England and Wales. METHOD: The questionnaire developed by the National Addiction Centre for research in England/Wales was used to collect data. It was mailed on two occasions (March and April 1999) together with a covering letter and a prepaid return envelope to all community pharmacies in Northern Ireland (n = 507). A final reminder letter was included in the local wholesalers' medical delivery for the attention of the pharmacist in May 1999. MAIN OUTCOME MEASURE: The extent to which Northern Ireland pharmacists had contact with and provided services to illicit drug users compared to pharmacists in England/Wales. RESULTS: A response rate of 67.5% was achieved. Respondents in Northern Ireland were providing fewer services to drug users than those in England/Wales. Respondents reported dispensing methadone for the treatment of addiction/misuse to only 9 patients, while only 17 pharmacists had been asked to sell injecting equipment in the previous week and no pharmacist was participating in a needle exchange scheme. However, most respondents indicated their willingness to provide such services. Barriers towards the provision of services were, however, highlighted e.g. the need for training and the establishment of support systems. CONCLUSION: Pharmacists in Northern Ireland are in a position to contribute to the policy agenda in Northern Ireland for drug misuse, prevention, treatment and harm minimisation--roles which the survey indicates they are willing to embrace. However, training programmes, support systems and adequate remuneration packages must be established before they will be in a position to participate fully.

England↗
PubMed2003

Profile of veterinarians and veterinary practice in Ghana.

This paper presents a profile of veterinary practice and veterinarians in Ghana, as assessed through secondary data and a questionnaire. In all, 123 veterinarians responded, giving a response rate of 85%. (123/145). Analysis of the secondary data from 1986-95 revealed that Veterinary Livestock Units (VLU) per veterinarian ranged from 10000 to 16000 and VLU per technical support staff ranged from 2000 to 3000. However, the distribution of the staff within the country was poor, resulting in very high ratios for the Northern, Upper East, Upper West and Volta Regions and low ratios for Central, Ashanti and Eastern Regions. The bulk of the respondents (78%) had 15 or fewer years of experience. with the overall mean being 12 years. The most common animal species handled were small ruminants and the most common activities were prevention/treatment of worms, surgery and giving advice. Lack of transport ranked highest among the constraints to veterinary work. The perceived determinants of effective and efficient service delivery were the availability and efficiency of means of transport, adequacy of logistics, remuneration for staff in rural posts and farmer education in husbandry practices. The respondents perceived poor management techniques of farmers and lack of credit as major factors hindering livestock production in Ghana. The implications of these and other findings are discussed.

Animal Husbandry↗
PubMed2003

Perceived oral health: changes over 5 years in one Swedish age-cohort.

OBJECTIVES: The purpose of this study was to investigate if a change in the social gradients in perceived oral health occurred over a 5-year period, 1992-97, using a cohort population from two Swedish counties. METHODS: In 1992, a cross-sectional mail questionnaire was sent to all 50-year-old persons in two counties in Sweden, Orebro and Ostergötland, and altogether there were 8888 persons. In 1997, the same population was sent a new questionnaire. The cohort, comprising the same respondents from 1992 and 1997, was of 5363 persons. An index of perceived oral health was constructed out of three questionnaire variables: satisfaction with teeth, chewing ability and the number of remaining teeth. This index value was set as a dependent variable in a regression model. Reports of toothache were investigated in a separate logistic regression model. RESULTS: There were obvious social gradients in the perceived oral health index both in 1992 and in 1997. Marital status, foreign birth, education and occupation were all substantially related to the perceived oral health. The change in perceived oral health was analyzed. Almost half of the cohort (47.4%) showed no change at all. Those with increased and those with decreased health were rather evenly distributed on both sides, with 22.0% with better health in 1997 and 30.6% with worse health. Gender and education were related to toothache experience. CONCLUSION: Changes have been moderate in the perceived oral health in this cohort, despite the rather drastic changes in the remuneration of dental care during this study time. On the other hand, this also means that the social differences remain, despite the official goals of increased equity.

Cohort Studies↗
PubMed1998

Is anterior chamber lens implantation after intracapsular cataract extraction safe in rural black patients in Africa? A pilot study in KwaZulu-Natal, South Africa.

PURPOSE: There are an estimated 16 million people blind from cataract world-wide. In many areas the routine operation is intracapsular cataract extraction (ICCE). The role of modern anterior chamber (AC) intraocular lenses (IOLs) is being explored, and they have been shown to be safe and successful in Asia. Are they equally safe in rural black African populations? METHODS: One hundred black patients aged 50 years and over who attended Edendale Hospital were enrolled in a pilot study of insertion of AC IOLs after ICCE. They were followed up for 6 months. RESULTS: With financial remuneration, the follow-up rate at 8 weeks increased from the usual 30% to 72%. At 6 months, 67% of eyes achieved a correlated visual acuity of 6/18 or better. Thirty per cent had persistent uveitis, 16% had peripheral anterior synechiae beyond the points of haptic contact, and 5% had an intraocular pressure greater than 21 mmHg. CONCLUSIONS: A randomised trial comparing ICCE with AC IOL and extracapsular cataract extraction with posterior chamber IOL is probably not justified at this time in this population. However, there may be wide variations in the reaction of the eyes of different African ethnic groups to IOLs. In view of the successful use of AC IOLs in Asian eyes, further pilot studies of AC IOLs may be warranted in other parts of Africa where ICCE is the routine procedure.

Black or African American↗
PubMed1990

The capitation study. 3. The views of participating dentists and the profession.

During the course of a 3-year parallel, controlled clinical trial comparing a capitation system of remuneration with fee-for-service for the dental care of children, the views of the dentists were gained through meetings, informal communication, and a structured questionnaire sent to every dentist in the study. The questionnaires completed by the dentists who had been in the study from the beginning were used in the analysis. The views of practice principals on practice administration were also gained. Dentists in capitation claimed to have greater clinical freedom than those in fee-for-service, but the system under test involved more practice administration. The trial allowed the two systems to be compared under limited, controlled conditions, thus benefiting any substantive scheme that might be developed from it.

Capitation Fee↗
PubMed1990

The specialist orthodontic practitioner. The 1989 survey.

In 1989, a survey of specialist orthodontic practitioners was carried out, with the cooperation of the British Association of Orthodontists. Questionnaires were sent to all BAO members in full-time specialist orthodontic practice; a 72% response was achieved. The results revealed that the specialist orthodontic practitioner service was well equipped and adequately qualified to accept a role as providers of the majority of UK orthodontic treatment. When new patient treatments were analysed, it was found that fixed appliance treatment was proposed for 60% of patients. However, the majority of the respondents felt that the system of remuneration in the GDS encouraged quantity as opposed to quality of treatment.

Adult↗