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At least 577 records · Page 32Linked to original sources
PubMed2001

Racial and ethnic differences in access to medical care in managed care plans.

OBJECTIVE: To examine the extent to which access differences between racial/ethnic minorities and whites in managed care plans are greater than such differences in other types of health plans. DATA SOURCE: A nationally representative sample of 4,811 African American, 3,379 Hispanic, and 33,737 white nonelderly persons with public or private health insurance. STUDY DESIGN/DATA COLLECTION: A cross-sectional survey of households was conducted during 1996 and 1997. Commonly used measures of access to and utilization of medical care were constructed for individuals: (1) percentage of visits with a usual provider, (2) percentage with a regular provider, (3) visit with a physician in the past year, (4) hospital ER use, (5) last visit was to a specialist. PRINCIPAL FINDINGS: Fewer than 74 percent of Hispanics and African Americans had a regular provider compared to more than 78 percent of white Americans. Hispanics were least likely to have had their last doctor visit with a specialist (22 percent) compared to African Americans (26 percent) and whites (28 percent). Differences between ethnic/racial minorities and whites in managed care plans are similar to differences observed in non-managed care plans. Americans of all racial and ethnic backgrounds in managed care plans with gatekeeping are more likely to have a usual source of care, a regular provider, and lower use of specialists compared to persons in plans without gatekeeping. CONCLUSION: Although greater access to primary care was shown among African Americans and Hispanics in managed care plans, the extent of the disparities between racial/ethnic minorities and whites in managed care is similar to disparities in other types of health plans.

Black or African American↗
PubMed1993

Visibility and the just allocation of health care: a study of age-rationing in the British National Health Service.

The British National Health Service (BNHS) was founded, to quote Minister of Health Aneurin Bevan, to 'universalize the best'. Over time, however, financial constraints forced the BNHS to turn to incrementalist budgeting, to rationalize care and to ask its practitioners to act as gatekeepers. Seeking a way to ration scarce tertiary care resources, BNHS gatekeepers began to use chronological age as a rationing criterion. Age-rationing became the 'done thing' without explicit policy directives and in a manner largely invisible to patients, to Parliament, and to the public. The invisibility of the practice, however, violates the publicity principle that John Rawls and other philosophers believe essential to fairness. BNHS invisible age-rationing practices are thus a test case of the principle that fairness presupposes publicity; they raise the question: is it possible to preserve equitability in a system that uses non-public criteria to allocate scarce resources? To seek an answer, published data on access to end-stage renal disease (ESRD) treatment in Britain and the European Community (EC) are analysed. Among the findings are: that BNHS age-rationing acts as an excuse for denying care to those most likely to need ESRD treatment; and is, moreover, arbitrary and inequitable. It is further argued that no age-rationing policy can sustain visibility, and that, if the BNHS is to be fair to its patients, it must reform its present age-rationing practices, replacing them by a publicly visible, outcome-based rationing policy that rations either in terms of QALYs or triage categories.

Age Factors↗
PubMed2005

Institutional arrangements and efficiency of health care delivery systems.

This study examined the efficiency of health care delivery systems in 24 OECD countries. Practicing physicians, practicing nurses, inpatient beds, and pharmaceuticals were considered as inputs to treat populations of various age groups. Data envelopment analysis (DEA) was utilized to calculate efficiency. We also calculated input efficiency that should be helpful in determining excess number of physicians, nurses, inpatient beds, and pharmaceuticals consumed. Institutional arrangements affect efficiency: public-contract and public-integrated countries are more efficient than public-reimbursement countries. Countries in which physicians are paid in wages and salaries and countries with capitation have higher efficiency than fee-for-service countries. Countries in which a primary care physician acts as a gatekeeper are also more efficient than countries without gatekeepers.

Delivery of Health Care↗
PubMed1991

Managing Medicare reimbursement on medical-psychiatry units.

Many general hospitals are confronting issues of financial strain precipitated to a large extent by Medicare payment reductions. The viability of psychiatry programs within general hospitals more than ever depends upon some demonstration of their financial as well as clinical contribution. The aim of this study is to review some of the basic parameters governing Part A (hospital) Medicare reimbursement of DRG-exempt general hospital psychiatry units and to provide options for improving their financial viability. There are a number of specific mechanisms involved in managing Medicare cost and reimbursement. Establishing a system for gatekeeping is important because significant control of payor mix and length of stay resides with the unit gatekeeper. Establishing liaison for short-stay patients with nursing home papers is important because Medicare pays on a target cost per discharge. The identification of short-stay patients is financially very favorable, and often critical to balance the unavoidable longer-stay patients. This paper also discusses how medical-psychiatric units can interface most effectively with medical-surgical units. Finally, there is some discussion of the need to develop pre- and postadmission outpatient medical-psychiatric programs. The financial aspects of medical-psychiatry care, if not the increasing scrutiny of managed care, will force further development of such outpatient programs.

Cost Control↗
PubMed1994

Managed care involvement by cardiovascular specialists: prevalence, attitudes and influence on practice.

OBJECTIVES: The purpose of this study was to determine the involvement in and attitudes toward managed care by cardiovascular specialists and the influence of such programs on their practices. BACKGROUND: No in-depth study has measured the impact of managed care on cardiovascular specialists. Therefore, we conducted a mail survey to determine the prevalence of managed care arrangements among cardiovascular specialists and variations among pediatric and adult cardiologists and cardiovascular surgeons; the types of managed care arrangements in which cardiovascular specialists are engaged; the reasons why those not participating in managed care have chosen not to do so; and the general attitudes among cardiovascular specialists with regard to various aspects of managed care. In addition, we evaluated the impact of managed care among several aspects of cardiovascular practice. METHODS: A questionnaire was mailed in the spring of 1993 to 4,577 practicing, domestic, American College of Cardiology (ACC) members selected at random from within each primary cardiovascular specialty group (adult cardiologists, pediatric cardiologists and cardiovascular surgeons). Additional data concerning practice characteristics were cross tabulated using results from the 1992 ACC membership profile survey. RESULTS: In total, 1,961 of the 4,577 members responded to the survey, representing a 43% response rate. Of all survey respondents, 76% reported entering into at least one relationship with a health maintenance organization (HMO) or preferred provider organization (PPO). Of those not participating in managed care arrangements, the most frequently mentioned reason was "concern over the quality of care." This reason was cited by 51% of those not entering into HMO relationships and 41% of those not participating in PPOs. The majority of respondents indicated that they do not strongly object to the gatekeeper approach to managing nonemergent patients, although more than half indicated concern that gatekeepers may not be appropriate in the management of cardiac emergencies. In addition, cardiovascular specialists report that under managed care, referrals have not increased, income has decreased, and managed care formularies have not substantially affected their ability to prescribe appropriate medication to their patients. CONCLUSIONS: Despite concerns over the quality of care and contract requirements and general philosophical opposition of cardiovascular specialists, most are becoming integrated into managed care environments.

Adult↗
PubMed2005

The architecture of the protein domain universe.

Understanding the design of the universe of protein structures may provide insights into protein evolution. We study the architecture of the protein domain universe, which has been found to poses peculiar scale-free properties. We examine the origin of these scale-free properties of the graph of protein domain structures (PDUG) and determine that that the PDUG is not modular, i.e. it does not consist of modules with uniform properties. Instead, we find the PDUG to be self-similar at all scales. We further characterize the PDUG architecture by studying the properties of the hub nodes that are responsible for the scale-free connectivity of the PDUG. We introduce a measure of the betweenness centrality of protein domains in the PDUG and find a power-law distribution of the betweenness centrality values. The scale-free distribution of hubs in the protein universe suggests that a set of specific statistical mechanics models, such as the self-organized criticality model, can potentially identify the principal driving forces of protein evolution. We also find a gatekeeper protein domain, removal of which partitions the largest cluster into two large sub-clusters. We suggest that the loss of such gatekeeper protein domains in the course of evolution is responsible for the creation of new fold families.

Databases, Protein↗
PubMed2006

Minimalist protein model as a diagnostic tool for misfolding and aggregation.

We propose a realistic coarse-grained protein model and a technique to "anchor" the model to available experimental data. We apply this procedure to characterize the effect of multiple mutations on the folding mechanism of protein S6. We show that the mutation of a few "gatekeeper" residues triggers significant changes on the folding landscape of S6. These results suggest that gatekeeper residues control the flexibility of critical regions of S6, that in turn regulates the delicate balance between folding and aggregation. Although obtained with a minimalist protein model, these results are fully consistent with experimental evidence and offer a clue to understand the interplay between folding and aggregation in protein S6.

Models, Chemical↗
PubMed2005

Inducible nitric oxide synthase expression is inhibited by myeloperoxidase.

Nitric oxide (NO) plays key roles in vasodilation and host defense, yet the overproduction of NO by inducible nitric oxide synthase (iNOS) at inflammatory sites can also be pathogenic. Here, we investigate the role of MPO in modulating the induction of iNOS by IFNgamma/LPS (IL). In monocyte-macrophages (Mvarphi) treated with IL, MPO gene expression was found to be downregulated as iNOS was upregulated. In Mvarphi from MPO-knockout (KO) mice, the induction of iNOS by IL was earlier and higher than in MPO-positive cells, suggesting MPO is inhibitory. Consistent with that interpretation, the addition of purified MPO enzyme to cultured macrophages inhibited iNOS induction by IL. In addition, an inhibitor of MPO enzyme, 4-aminobenzohydrazide, enhanced iNOS induction in MPO-positive cells, but not in MPO-KO cells. Similarly, taurine, a scavenger of MPO-generated HOCl, enhanced iNOS induction in MPO-positive cells, but not in MPO-KO cells. MPO affects an early event, suppressing iNOS induction when added within 2h of IL, but not when added several hours after IL. The suppression by MPO was alleviated by NO donor, sodium nitroprusside, suggesting the suppression results from scavenging of NO by MPO. This interpretation is consistent with earlier reports that MPO consumes NO, and that low levels of NO donor augment induction of iNOS by IFNgamma/LPS. The implication of these findings is that MPO acts as gatekeeper, suppressing the deleterious induction of iNOS at inflammatory sites by illegitimate signals. The combined signaling of IFNgamma/LPS overrides the gatekeeper function by suppressing MPO gene expression.

Animals↗
PubMed2006

Fetal programming: causes and consequences as revealed by studies of dietary manipulation in rats -- a review.

During pregnancy, the developing fetus is dependent on its mother for all nutritional requirements. It is not surprising, therefore, that variations in maternal nutrition can be reflected in alterations in fetal health and well-being. Interestingly, the changes can persist into adulthood and may result in increased risk of diseases such as diabetes, obesity and cardiovascular disease. The first observations of these phenomena resulted in the development of hypotheses collectively brought under the heading of "fetal" or, more recently, "developmental" programming. In this review, we will examine some of the animal models used to understand the mechanisms involved and attempt to determine whether there are common, "gatekeeper", pathways or genes, altered by the different nutritional stresses. We will concentrate primarily on nutrition related to post-natal development of hypertension and will restrict the review to studies in rodents, since that is where most of the mechanistic studies are being undertaken. Our conclusions are that, while there may well be some common gatekeeper pathways, there is also some diversity of mechanism which may contribute to the generation of the same or similar phenotypes.

Adaptation, Physiological↗
PubMed2006

Protein aggregation and amyloidosis: confusion of the kinds?

Recent years have witnessed major advances in our understanding of the structural basis of protein aggregation on several fronts. Firstly, high-resolution structural information that remained elusive for many years was provided by a series of studies of amyloid fibers using NMR, X-ray crystallography and electron microscopy, thereby confirming earlier models based on lower resolution observations. Secondly, studies of the sequence determinants of protein aggregation culminated in the development of computer algorithms that predict aggregation-prone sequences with good accuracy, allowing the design of mutations that reduce aggregation. Thirdly, based on the first results from such predictions and on statistical analysis of naturally occurring aggregating sequences, a picture is emerging in which aggregation-prone sequences are capped by gatekeeper residues that oppose aggregation. In addition to their aggregation-opposing function, it seems that gatekeeper residues are also important in determining chaperone selectivity for strongly aggregating regions. Finally, recent computational and experimental work shows that preventing aggregation does not necessarily mean that amyloid formation is prevented and vice versa. Thus, although aggregation and amyloidosis correlate to a certain extent, they are different processes and should be treated as such.

Algorithms↗
PubMed2005

K(ATP) channels "vingt ans après": ATG to PDB to Mechanism.

A multidisciplinary effort over twenty years has provided deep insight into the nature of K(ATP) channels. First discovered in cardiomyocytes and pancreatic beta-cells, as ubiquitous sensors of the ADP/ATP ratio they are implicated in multiple disorders characterized by the uncoupling of excitation from metabolism. Composed of two disparate subunits these large octameric channels present a formidable challenge to scientists interested in understanding mechanism in physical, chemical, and structural terms. Post-cloning studies have defined the domains and interactions, within and between the nucleotide-inhibited K(IR) pore and nucleotide-stimulated, drug-binding core of the ATP-Binding Cassette (ABC) regulatory subunits, that control channel assembly and gating. Determination of the three-dimensional structures of the bacterial prototypes of the channel subunits allowed homology modeling and has provided increasingly detailed mechanistic understanding. Here I review the early electrophysiology and molecular biology of K(ATP) channels, cover biophysical principles governing their single channel kinetics, integrate this with current efforts to understand ligand-recognition and gating within the pore and SUR core, and propose a mechanism of coupling based on recent identification of a SUR gatekeeper module and first composite models of (SUR/K(IR) 6.0)(4) complexes. This mechanism, based on interactions between inter-K(IR) subunit ATP-binding pockets and a unique bi-directional regulatory apparatus comprised of elements from the gatekeeper and K(IR) amino terminus, provides a molecular perspective for understanding the biophysical basis underlying the polar effects of pathogenic mutations in K(ATP) channel subunits.

ATP-Binding Cassette Transporters↗
PubMed2000

All rights reserved, or can we just copy? Cost sharing arrangements and characteristics of health care systems.

In most European countries cost sharing has been introduced in order to reduce the demand for care. Different forms of cost sharing are available, but because of historically grown system characteristics and prevailing values countries differ in the application of specific forms. This review focuses on eighteen European countries, and on the combinations of health system characteristics and present forms of cost sharing. We found that some combinations are more present: different payment systems for primary care physicians go together with different forms of cost sharing, different services have different forms of cost sharing. In countries with a GP as gatekeeper no charges are in use for the GP. No distinct relationship could be found between the financing system (tax-based or insurance-based) and the form of cost sharing or the exclusion of vulnerable populations. It is concluded that there are two ways of filtering 'unnecessary' demand. One is by introducing cost sharing for directly accessible services such as GPs. The second way is by having GPs act as gatekeepers to more specialized, and more costly care.

Cost Sharing↗
PubMed1996

Quality of care: issue or oversight in health care reform?

BACKGROUND: Health care reform is not dead but merely on hiatus. The vehicle for the reform is managed care, in particular health maintenance organizations (HMOs). HMOs employ primary care physicians as gatekeepers to act as regulators and points of entry into the health care system. It is through these gatekeepers that most dermatologic care is rendered. OBJECTIVE: Our purpose was to assess (1) the level of dermatology training of family practice physicians compared with dermatologists and (2) the impact on the delivery of quality dermatology services. METHODS: a national study of university residency programs was undertaken. Twenty color Kodachromes of typical cutaneous diseases were analyzed by the two physician groups. A questionnaire was used to evaluate the average formal dermatology training received, the number of primary dermatology patients examined by family practitioners, the correct response rates to the questions, and the dermatologic procedures performed by family practitioners. A total of 723 family practice physicians and 443 dermatologists responded. RESULTS: Our results indicate that, in comparison to dermatologists, primary care physicians significantly are deficient in their ability to recognize common and serious dermatoses. CONCLUSION: this study provides data emphasizing the need for reevaluation of the dermatology curriculum in medical schools and family practice residencies. Most important, it suggests that direct access to dermatologists provides better quality of care to members of HMOs and hence indirectly is most cost effective for the provision of dermatology services.

Cost-Benefit Analysis↗
PubMed1998

General practice in urban and rural Europe: the range of curative services.

The variation in the range of services provided by general practitioners (GPs) is not only related to personal characteristics and features of the country's health care system but also to the geographical circumstances of the practice location. In conurbations health services are more widely available than in the countryside, where GPs often are the only providers. With highly mobile populations and a plentiful supply of doctors, in cities the prevailing regulations for access and use of services are more difficult to maintain. It is also more difficult to control access and thus opportunities for inappropriate use are greater. Against this background an international study was conducted on variation in task profiles of GPs, especially focusing on differences between urban and rural practices. In 1993 standardised questionnaires in the national languages were sent to samples of GPs in 30 countries. Various aspects of service provision were measured as well as practice organisation, location of the practice and personal backgrounds of the GP. Completed questionnaires were received from 7,233 respondents, an overall response rate of 47%. Sources of variation have been analysed by using a two-level model. Rural practices provided more comprehensive services regardless of the health care system. Approximately half of the variation was explained by features of a country's health care system. The GP's position at the point of access to health care was strongly associated with the gatekeeper function controlling access to secondary care. In western countries where the GPs were self employed they had greater involvement in technical procedures and chronic disease management. There was a considerable gap between the task profiles of GPs in eastern and western Europe. We found evidence of a reduced gatekeeper role in inner cities in those countries where GPs held this position. GPs with an estimated overrepresentation of socially deprived people and elderly in the practice population reported a wider range of services. Differences also appeared to be related to factors which are largely controlled by the individual doctor, such as level of training and education, availability of equipment and practice staff. The results have important implications for education, policy development and health care planning both in eastern and western Europe.

Adult↗
PubMedDate not supplied

Setting health standards for the 21st century.

OBJECTIVES: To describe the nature, substance, and impact of health standards and to speculate on how they may change during the early years of the 21st century. SUMMARY: The health care system has experienced dramatic changes over the past three decades. Health standards now cover the spectrum from statutes to regulations to guidelines, as well as less compulsory forms, and address every aspect of health, including the availability, quality, and cost of services; the safety, efficacy, and quality of products; the adequacy of processes and analytic methods; and the value and cost-effectiveness of health technologies and services. Standards cover promotion, protection, and gatekeeping functions. They are established in response to specific needs and are driven by social and political agendas; social policy will drive standards development to a greater extent in the 21st than in the 20th century. Technology advances are stimulating new forms of standards, primarily gatekeeping standards. Standards raise the question of compliance. The trend is increasingly toward less compulsory, more discretionary standards, with a greater percentage being established by quasi-official and voluntary bodies. CONCLUSION: 21st century health standards must balance the rights of access with protection from unsafe, ineffective, and poor quality products and services during a period when decisions must be made faster. They must be more flexible, enabling consumers to choose their level of protection. Such standards will pose the same concerns about adequacy, equity, and freedom of choice as health standards pose now. Whether we will use 21st century standards to improve and advance our health as well as systems, products, and services that contribute to health more effectively than we have in the 20th century is a question to ponder.

Forecasting↗
PubMed2002

Caretaker tumour suppressor genes that defend genome integrity.

Cancers arise as a result of genetic changes that impact upon cell proliferation through promoting cell division and/or inhibiting cell death. Tumour suppressor (TS) genes are the targets for many of these genetic changes. In general, both alleles of TS genes must be disrupted to observe a phenotypic effect. Broadly speaking, there are two types of TS gene: 'gatekeepers' and 'caretakers'. In contrast to gatekeepers, caretaker genes do not directly regulate proliferation, but act to prevent genomic instability. Thus, mutation of caretaker genes leads to accelerated conversion of a normal cell to a neoplastic cell. Many caretaker genes are required for the maintenance of genome integrity. This review focuses on those caretaker genes that play a role, directly or indirectly, in the repair of DNA strand breaks by the homologous recombination pathway, and that are associated with cancer-prone clinical syndromes, in particular ataxia telangiectasia, hereditary breast cancer, Bloom's syndrome and Werner's syndrome.

Animals↗
PubMed1998

Factors associated with referral to psychiatric care by general practitioners compared with self-referrals.

BACKGROUND: The gatekeeper function of the general practitioner (GP) in the pathway to specialized psychiatric services was investigated in this study, which is part of the Nordic Comparative Study on Sectorized Psychiatry. The question addressed in this paper is whether different sociodemographic and clinical factors as well as factors related to service utilization are associated with referral from the GP compared with self-referrals (including referrals from relatives). METHODS: The study comprised a total of 1413 consecutive patients, admitted during 1 year to five psychiatric centres in four Nordic countries. The centres included in this study were those that accepted non-medical referrals. Only new patients (not in contact with the service for at least 18 months) were included. RESULTS: Increasing age was the only sociodemographic factor significantly associated with referral by the GP. The clinical factors (psychosis, being totally new to psychiatry and being in need of in-patient treatment) and some treatment characteristics (planned out-patient treatment and involuntary in-patient treatment), were all significantly associated with referral by the GP. Some indication was found that self-referred patients have shorter episodes of care. CONCLUSIONS: The findings were remarkably stable across the different centres indicating a general pattern. This study extends previous work on the role of GPs in the pathway to specialized psychiatric services and indicates that the GP has an important gatekeeper function for the most disabled patients.

Adolescent↗
PubMedDate not supplied

SENECA: A platform-independent, distributed, and parallel system for computer-assisted structure elucidation in organic chemistry.

The program package SENECA for Computer-Assisted Structure Elucidation (CASE) of organic molecules is described. SENECA is written completely in the programming language Java and divided into a server, a client, and a gatekeeper part. While the client allows for input of spectroscopic information, the server part performs the actual structure elucidation by stochastically walking through constitution space while optimizing the molecule toward agreement with given spectral properties. The convergence is guided by simulated annealing. The gatekeeper administers a list of server processes, which can be retrieved by the client. The package is completely platform-independent and its server part can be distributed over the Internet or an intranet using a heterogeneous network of almost any number and type of computers, thus allowing for parallel CASE computations on ordinary networks, present in almost any institution.

Journal Article↗