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PubMed2006

Ethical philanthropy in academic psychiatry.

OBJECTIVE: From an ethical perspective, psychiatrists cannot accept gifts of significant monetary value from their patients. This guideline raises important questions regarding institutional practices related to gift-giving in academic psychiatry. The first aim of this article is to explain the ethical tensions and shared ethical commitments of the professions of psychiatry and philanthropy. The second aim is to outline a series of steps that may be undertaken to assure ethical philanthropic practices within an institution, including the establishment of a committed advisory workgroup and the creation of ground rules and safeguards for gift-giving. Each situation should be evaluated for "ethical risk," and specific measures to safeguard donors should be considered. METHOD: The author outlines methods to manage, minimize, or eliminate conflict of interest issues, including identification and disclosure of conflicting interests, role separation, goal clarification, confidentiality protections, proper timing, and ongoing oversight. Three case illustrations are provided and discussed. RESULTS: The process of institutional engagement, dialogue, and shared problem-solving is especially important. A shared, constructive ethic will be attained only if leaders and diverse stakeholders communicate the value of the new approach through their words, expectations, and actions. CONCLUSIONS: Through these efforts, greater attention will be given to the concerns of people with mental illness, and academic institutions may be better able to fulfill their responsibilities to this important but neglected population now and in the future.

Academic Medical Centers↗
PubMed1997

The successful implementation of pharmaceutical practice guidelines. Analysis of associated outcomes and cost savings. SWiPE Group. Systematic Withdrawal of Perioperative Expenses.

BACKGROUND: Although approximately 2,000 medical practice guidelines have been proposed, few have been successfully implemented and sustained. We hypothesized that we could develop and institute practice guidelines to promote more appropriate use of costly anesthetics, to generate and sustain widespread compliance from a large physician group, and to decrease costs without adversely affecting clinical outcomes. METHODS: A prospective before and after comparison study was performed at a tertiary care medical center. Clinical outcomes data and times indicative of perioperative patient flow were collected on the first of two sets of patients 1 month before discussion of practice guidelines. Practice guidelines were developed by the physicians and their associated care team for the intraoperative use of anesthetic drugs. A drug distribution process was developed to aid compliance. Clinical outcomes data and times indicative of perioperative patient flow were collected on the second set of patients 1 month after institution of practice guidelines. Hospital drug costs and adherence to guidelines were noted throughout the study period and for each of the following 9 months by querying the database of an automated anesthesia record keeper. RESULTS: A total of 1,744 patients were studied. Drug costs decreased from 56 dollars per case to 32 dollars per case as a result of adherence to practice guidelines. Perioperative patient flow was minimally affected. Time (mean +/- SD) from end of surgery to arrival in the post-anesthesia care unit (PACU) increased from 11 +/- 7 min before the authors instituted practice guidelines to 14 +/- 8 min after practice guidelines (P < 0.0001). Admission of inpatients to the PACU receiving monitored anesthesia care increased from 6.5 to 12.9% (P < 0.02). Perioperative patient flow and clinical outcomes were not otherwise adversely affected. Compliance and cost savings have been sustained. CONCLUSIONS: This study is an example of a successful physician-directed program to promote more appropriate utilization of health care resources. Cost savings were obtained without any substantial changes in clinical outcomes. Institution of similar practice guidelines should result in pharmaceutical savings in the range of 50% at tertiary care centers around the country, with a slightly smaller degree of savings expected at institutions with more ambulatory surgery.

Anesthesiology↗
PubMed2002

Using family-style meals to increase participation and communication in persons with dementia.

Although researchers stress the importance of encouraging independent behavior in persons with dementia, institutional practices often foster dependence. This study took place in a six-resident locked dementia care unit that followed the common institutional practice of serving meals on prepared plates. The purpose of this study was to examine if changing the mode of meal delivery to "family-style," where residents were presented with serving bowls and empty plates, would increase resident communication and participation in mealtime tasks. An ABAB' reversal design revealed very low rates of appropriate communication (5% of intervals) and mealtime participation (10% of tasks) during baseline, when residents received prepared plates (A). Communication and participation doubled when family-style meal delivery was introduced (B) and dropped back to baseline levels when it was withdrawn (A). Because the levels of communication and participation during family-style meals were still low, the nursing assistant was provided with instruction on prompting and praising appropriate mealtime behaviors (B'). After instruction was provided and family-style meals were reintroduced, resident participation rose to 65% of tasks and appropriate communication increased to 18% of observations. This study suggests family-style meals may result in modest increases in mealtime participation and communication of residents with dementia, but staff training in prompting and praising may be necessary to see large changes in these behaviors.

Aged↗
PubMed1975

Implications of certificate of need legislation for institutional pharmacy practice.

Federal certificate of need legislation (Section 1122 of Public Law 92-603)aimed at the elimination of costly, duplicative or unneeded health care expenditures is discussed. This law applies only to institutional providers receiving federal reimbursements. The key issues for pharmacy are that proposed substantial changes in service and capital expenditures of $100,000 or more must be justified to local and state comprehensive planning agencies prior to implentation. Failure to comply with the legislation can result in a reduction or withholding of federal reimbursement.

Costs and Cost Analysis↗
PubMed2000

Treatment of elderly women with urge incontinence in middle tennessee: a single institution practice-based study.

INTRODUCTION AND OBJECTIVES: Urinary urge incontinence (UUI) is a major factor in reducing quality of life in elderly women. The treatment of UUI in the elderly population is complicated by comorbidities, polypharmacy, cost, and side effects. The purpose of this study was to examine our practice pattern in Middle Tennessee for the treatment of elderly women with UUI. METHODS: We retrospectively reviewed the medical records of all women over age 65 seen at our institution between January 1, 1998 and September 1, 1999 with an initial complaint of pure UUI. Diagnosis was based on history and physical examination by a single urologist (JJF). Initial treatment in all patients was medication as well as timed and double voids. Medication chosen was based on cost factors, co-morbidities, current medications, and outcome from previous treatment. RESULTS: Of 53 women ranging in age from 65-87 years of age (avg. 74.7) included in this study, 6/53 (11.3%) had a previous CVA, and 2/53 (3.7%) had grade I-II cystoceles. Initial pharmacologic treatment included anticholinergic medication in 47 patients (88.6%), and either imipramine or topical estrogen alone in the remaining 11.4%. Of the anticholinergics, hyoscyamine time capsules were used in 29, tolterodine in 7, standard oxybutynin in 5, oxybutynin XL in 1, and a combination with imipramine in 5. Thirty-four of the 53 total patients (64.1%) discontinued their medications because of no improvement 14 (41.1%), dry mouth 9 (26.4%), other side effects 9 (26.4%), cost 1, and other reasons in the remaining 2 patients. Only 17 patients (32%) stated they were doing well on their initial medications; 11 of those (64.7%) were taking hyoscyamine time capsules. Upon subjective failure, 22/36 patients (61.1%) had their medications changed, while 14/36 (38.8%) pursued behavioral therapy without additional medications. Urodynamic studies were done in 12 patients who failed empiric medical treatment (22.6%). CONCLUSIONS: Only 32% of elderly women treated medically for UUI were satisfied and continued therapy in this patient population. One-fourth of elderly women failed empiric medical management of UUI due to lack of efficacy, and one-third due to intolerable side effects. In this practice, hyoscyamine was continued more often than any other anticholinergic because of reasonable cost, efficacy, and side effect profile.

Aged↗
PubMed1996

Structure and practice of institutional review boards in the United States.

OBJECTIVE: The institutional review board (IRB) is a critical element in the protection of patients' and subjects' rights with regard to their participation in research protocols. The purpose of this study was to describe the structure and current practices of IRBs in the United States. METHODS: A self-administered questionnaire was mailed to the IRB chair of each U.S. hospital with a capacity of at least 400 beds (n = 907). The survey contained 21 questions outlining committee size and structure, review of research proposals, and policies concerning scientific misconduct. Chairs also were asked what advice they would offer a young investigator preparing a proposal for submission. RESULTS: A total of 488 surveys (54%) were returned; 447 of the responding institutions had an IRB committee. Committees had an average of 14 members, representing 27 medical specialties. Orthopedics had the least IRB representation (10% of committees), followed by emergency medicine (12%) and ophthalmology (15%). The majority of research proposals go through 5 specific steps once submitted for review. Common reasons for proposal rejection were improperly designed consent form (54%), poor study design (44%), unacceptable risk to subjects (34%), ethical or legal reasons (24%), and scientific merit (14%). When a research proposal is rejected, 86% of the responding IRBs assist the investigator in making appropriate revisions. Although a number of IRBs (17%) have dealt with scientific misconduct allegations, only 58% have a written policy regarding research integrity. CONCLUSION: Despite variations in committee structure and representation, IRBs have similar procedures for governing research. Investigators should be familiar with these procedures and are encouraged to discuss their proposal with an IRB representative prior to formal review.

Ethics, Institutional↗
PubMed2001

Solitary blood cultures: a College of American Pathologists Q-probes study of 132,778 blood culture sets in 333 small hospitals.

OBJECTIVE: To determine the frequency with which solitary blood culture samples were submitted to laboratories serving small hospitals and to ascertain whether certain hospital practices relating to the performance of blood cultures were associated with lower solitary blood culture rates (SBCRs). DESIGN: Participants in the College of American Pathologists Q-Probes laboratory quality improvement program collected data prospectively on the numbers of solitary blood culture sets from adult patients submitted to their laboratories and answered questions about their institutions' practice characteristics relating to the collection of blood culture specimens. SETTING AND PARTICIPANTS: Three hundred thirty-three public and private institutions with a median occupied bed size of 57. Participants were located in the United States (n = 329), Canada (n = 3), and Australia (n = 1). MAIN OUTCOME MEASURE: The solitary blood culture rate was defined as the number of instances in which only 1 blood culture venipuncture was performed on an individual patient during a 24-hour period divided by the total number of blood culture venipunctures that were performed during the study period. RESULTS: Participants submitted data on 132 778 adult patient blood culture sets. The SBCRs were 3.4% or less in the top-performing 10% of participating institutions (90th percentile and above), 12.7% in the midrange of participating institutions (50th percentile), and 42.5% or more in the bottom-performing 10% of participating institutions (10th percentile and below). In half the participating institutions, the SBCRs for inpatients were 8.3% or less and for outpatients, 22% or less. Solitary blood culture rates were lower for institutions in which phlebotomists rather than nonphlebotomists routinely collected blood culture specimens, in which internal policies required drawing at least 2 blood culture sets, in which hospital personnel contacted clinicians when their laboratories received requests for solitary blood culture sets, and in which quality control programs monitored SBCRs routinely. CONCLUSIONS: Hospitals can achieve SBCRs under 5%. Those hospitals with particularly high SBCRs may lower their rates by altering certain institutional practices.

Adult↗
PubMed2000

Safeguarding good scientific practice: new institutional approaches in Germany.

After summarising three recent case histories of alleged scientific misconduct in Germany, the efforts of the Deutsche Forschungsgemeinschaft (German Research Council) and the Hochschulrektorenkonferenz (German Rectors' Conference) to promote academic and procedural safeguards in favour of professional self-regulation in science and scholarship are described in outline.

Ethics↗
PubMed1999

How to design and implement your children's services outcomes management program: a practical training institute for child welfare, behavioral health, and substance abuse services.

During the two-day conference, attendees met in groups to discuss the information provided and concerns or problems they were having regarding outcomes within their own organizations. Subjects addressed included current and future outcomes measurement requirements, determination of good outcomes measures for behavioral health care organizations, effective collection of outcomes data, and use of outcomes data to improve services. Throughout the conference sessions, attendees were reminded to use the outcomes measures and their results to manage and change; include all the pertinent (internal and external) players that will help with the measurement process; define a specific strategy to follow; and keep data collection simple (if people aren't able to collect the data, then collection won't occur).

Adolescent↗