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PubMed2001

Work in progress. Integrating physicians' services in the home.

OBJECTIVE: While increasing acuity levels and the concomitant complexity of service demand that physicians be involved in in-home care, conflicting evidence and opinions do not show how this can best be achieved. DESIGN: A phenomenologic research design was used to obtain insights into the challenges and opportunities of integrating physicians' services into the usual in-home services in London, Ont. SETTING: Home care in London, Ont. PARTICIPANTS: Twelve participants included three patients, two family caregivers, two family physicians, the program's nurse practitioner, two case managers, and two community nurses. METHOD: In-depth interviews with a maximally varied purposeful sample of patients, caregivers, and providers were analyzed using immersion and crystallization techniques. MAIN FINDINGS: Findings revealed the potential for enhanced continuity of care and interdisciplinary team functioning. Having a nurse practitioner, interdisciplinary team-building exercises and meetings, regular face-to-face contact among all providers, support for family caregivers, and 24-hour coverage for physicians were found to be essential for success. CONCLUSION: Integration of services takes time, money, and sustained commitment, particularly when undertaken in geographically isolated communities. Informed choice and a fair remuneration system remain important considerations for family physicians.

Adult↗
PubMed2001

[Utilization of family practice by unemployed persons. Results of a survey of 250 family and primary care physicians].

The results of a questionnaire-based poll of 25 general practitioners from five German Länder show that providing medical care to the jobless confronts the family doctor with specific personal and health problems requiring more treatment time and more comprehensive medication--including antidepressants and tranquilizers--than age-matched working patients. Most practitioners had a skeptical attitude towards cooperation with institutions offering options to the jobless. Family doctors are faced with the dilemma of not being able to delegate the resolution of the patients' personal problems to others, while having no opportunity of obtaining remuneration from health insurance carriers for the time they spend counseling these patients.

Family Practice↗
PubMed2002

What motivates lay volunteers in high burden but resource-limited tuberculosis control programmes? Perceptions from the Northern Cape province, South Africa.

SETTING: The Northern Cape province, Republic of South Africa. OBJECTIVES: To explore factors that motivate lay volunteers to join tuberculosis (TB) control programmes in high burden but resource-limited settings. DESIGN: A qualitative study consisting of three focus group discussions and a documentary review of the records of 347 lay volunteers involved in the tuberculosis programme in the Northern Cape province of South Africa. Additional data were also collected in a cross-sectional study that involved questionnaire interviews with 135 lay volunteers. SUBJECTS: Lay volunteers in the TB programme. One focus group discussion was also carried out with youth not involved in the TB programme. RESULTS: Volunteers do not receive any monetary incentives in the TB programme in the Northern Cape province, but due to the high level of unemployment in this setting, hope for eventual remuneration was found to be the strongest factor motivating youth to join the programme. The study found attrition rates among volunteers to be high (22% had dropped out of the programme within one year of joining); 75% of the dropouts gave loss of interest and a desire for paid work as the reasons for leaving the TB programme. Other motivating factors identified included altruism, a need to find something to do with one's spare time, gaining work experience, and the novelty of the community-based TB programme. CONCLUSION: In the absence of monetary incentives, attrition rates of lay volunteers may be high and this can threaten the effectiveness of community-based TB programmes. In resource-limited settings, it is important to identify and implement appropriate alternative incentives that could motivate lay persons in order to sustain community participation in high TB burden areas.

Adolescent↗
PubMed2002

Family physicians and psychiatrists. Qualitative study of physicians' views on collaboration.

OBJECTIVE: To understand how to improve collaboration between psychiatrists and family physicians in primary care settings. DESIGN: Qualitative study using 10 in-depth interviews and a focus group session. SETTING: Catchment area in eastern Montreal, Que. PARTICIPANTS: Five FPs and five psychiatrists. METHOD: Ten interviews and a focus group were conducted to identify ways of improving collaboration between FPs and psychiatrists. All session were audiotaped and transcribed verbatim. Analysts used Atlas.ti to compare findings vertically and horizontally. MAIN FINDINGS: Three strategies were identified: communication, continuing medical education (CME) for FPs, and access to consulting psychiatrists. The first two can be implemented by FPs and psychiatrists together, but psychiatrists thought the last one was not feasible due to lack of both time and remuneration for such activity. CONCLUSION: Better communication and CME for FPs in psychiatry can help improve collaboration between FPs and psychiatrists. Increased access to consulting psychiatrists requires substantial alteration in established clinical roles and routines.

Attitude of Health Personnel↗
PubMed2002

[Balance disorders: a proposal of a new diagnostic methodology from the medico-legal standpoint].

Balance impairment is the object of requests for remuneration in 20-50% of the cases of cranial trauma. Most patients present slight disequilibrium following cranial traumas not involving concussion or cervical distraction. The various methods used in Italy to evaluate the biological damage score balance annoyances on a percentage basis ranging from 1% to 25% and base evaluation on vestibular testing results. The Authors feel that such evaluation approaches are limited. Indeed, since compensation mechanisms come into play, vestibular lesions are not always symptomatic. This means that the lesions detected solely through vestibular testing are not necessarily indicative of the extent to which the subject is affected. Furthermore, some extravestibular lesions can give rise to balance impairments which will go undetected by vestibular examination. Finally, an universally accepted diagnostic protocol still doesn't exist. In this work the Authors present a new method for balance impairments evaluation. While this technique still involves the normal evaluation range for vestibular damage (1-25%), it is based on the disturbance indicated by the patient rather than on the instrumentally detected damage. To objectively determine the real existence of the symptom, the Authors also propose a specific diagnostic strategy for each symptom, thus overcoming the problem of a diagnostic standard. The initial results, obtained on 56 subjects evaluated for post-traumatic balance impairment, show substantial agreement with previous methods. Our method allows to better recognize modest damage--for the most part extravestibular which go unrecognized with the conventional methods--and significantly modify the amount of more extensive damage, expression of vestibular damage which does not correspond to equally significant symptoms.

Craniocerebral Trauma↗
PubMedDate not supplied

The required number of physicians: is it an optimal figure?

Apart from the developing countries in which the number of physicians is extremely low, the number of physicians in the different countries shows a wide range even if it is comparing with the GDP or even with the number of nurses. According WHO data there are more than 500 physicians/100,000 inhabitants in Cuba and in Italy; more than 400 in Belarus and Norway, or in Spain and Georgia; more than 300 in 22 countries among them Belgium, France, Germany and Greece, Sweden, Switzerland, or Bulgaria, Czech, Hungary, Slovakia, Lithuania, etc. The number of doctors is below 300/100,000 inhabitants for example in such rich countries as the Netherlands, and the USA, and below 200 in the United Kingdom or in Japan. There is no correlation between the GDP and the number of doctors, as well as between the average life expectancy (or GBD, DALY, DALE) and the number of doctors. (On the other hand there is good correlation between GDP and life expectancy.) There is no correlation between GP-s and specialists, but it may be a weak correlation between the number of hospital beds and the number of doctors. It is difficult to find an optimal doctor/nurse ratio among the different countries; nevertheless the definition of "nurses" has a different meaning in the different countries. The burden of diseases, or the "patients" load" is also not an objective reference point, because the more the doctors, the more the patients. In the different countries there are different norms of the physicians' performances mainly decided by the health insurance funds. The different reimbursement systems, as the "per capita" at the GP-s, or the DRG at the hospital care, or the point-based remuneration at the specialist care are the real rate limiting factors for the number of physicians, which are not necessarily adequate to the professional requirements.

Developing Countries↗
PubMed2002

[What explains the growth of national insurance expenditure for primary health care?].

BACKGROUND: Fee-for-item payments are the main source of remuneration for primary care physicians in Norway. Physicians receive a major part of these payments from the National Insurance Administration. The present study describes the development in the National Insurance Administration expenditure for primary physician services in Norway from 1990 to 2000. MATERIAL AND METHODS: The analyses were performed on accounting data from the National Insurance Administration and data on the number of physician per 10,000 population from Statistics Norway. RESULTS: From 1990 to 2000, expenditure increased by 84%, from NOK 863.8 million to NOK 1.58 billion. Our main finding is that a substantial part of this increase can be explained by increases in the number of primary care physicians, population size, and the level of fees. INTERPRETATION: One interpretation of our findings is that National Insurance Administration expenditure on primary physician services to some extent can be controlled by regulating the number of physicians practicing with reimbursement from the National Insurance Administration and the level of fees.

Fee-for-Service Plans↗
PubMed2002

[A review of methods for controlling medical costs from the point of view of cost-effectiveness].

Cost-effectiveness analysis is a method used to evaluate the outcomes and costs of treatments or interventions designed to improve health. It has been widely regarded as an important aid to providing health care services efficiently. This paper reviews several measures for controlling medical costs in Japan, where a fee-for-service system is employed to remunerate for medical services provision. From the point of view of cost-effectiveness, the first step in health care reform for controlling medical costs should be minimizing useless medical services because the cost-effectiveness ratio of these tends to infinity. For the purpose of minimizing unserviceable provision in the field of medicine, two approaches must be considered. One is establishing a system so that physicians can act as perfect agencies for their patients. The other is encouraging academic research on the effectiveness of medical services.

Cost Control↗
PubMed1989

[Women, development and population in Latin America].

Women's situation as defined according to cultural factors which are present both in the division of labor by sex and in the power relationships, has its own specificities in the different social groups of a society. This happens for material reasons as well as because prevalent ideologies vary, among the different groups, from very traditional models of sexual roles to others which allow a greater flexibility in these roles. The consequences are reflected in the reproductive behavior. A woman's social insertion affects her specific situation, through a set of closely related variables: the educational opportunities, the quantity and characteristics of the domestic work they must carry out and the opportunities to participate in paid work. These variables influence demographic behavior through the age at 1st marriage, infant mortality, the values assigned to children and the capacity of taking reproductive decisions. In order to improve the situation of poorer women it is necessary that the economic, social and cultural development give special benefits to that sector, greater educational opportunities which could lead to possibilities of stable and well remunerated work. In these conditions women could achieve a greater self-determination to establish more equitable conjugal relationships and to decide with more freedom the number of their children.

Developing Countries↗
PubMed1988

Advisory Council on the Status of Women Act, 17 May 1988.

This Act establishes a Prince Edward Island Advisory Council on the Status of Women with members appointed by the Lieutenant Governor in Council. The Advisory Council is to do the following: "1) develop public awareness of the issues affecting the status of women; 2) promote a change in attitudes within the community in order that women may enjoy an equality of opportunity; 3) encourage discussion and expression of opinion by Island residents on issues affecting the status of women; 4) advise the Minister with respect to such issues as the Minister may refer to the Council for consideration; 5) review policies and legislation affecting women and report its findings to the relevant governmental departments or agencies; 6) provide assistance to the Minister in promoting changes to ensure the attainment of equality objectives of women; and 7) provide assistance, as the Council deems appropriate, to organizations and groups whose objectives promote the equality of women." Further provisions of the Act relate to the powers, meetings, remuneration, budget, staff, and annual reports of the Council, among other things.

Americas↗
PubMed1988

Decree No. 18729-J of 25 October 1988.

This Decree authorizes the association "Credimujer" to be inscribed in the Register of Associations of Costa Rica. Among the objectives of the "Credimujer" are the integration of women into the social and economic development of Costa Rica, improvement of the social and economic position of women, support of businesses run by women and business activities carried out by women, creation of opportunities for women to obtain credit, promotion of women in managerial positions, just remuneration for women, and contributions to the growth of businesses of which women are the beneficiaries.

Americas↗
PubMed1988

Hayward v. Cammell Laird Shipbuilders, 5 May 1988.

The appellant canteen cook charged the respondent employer with sex discrimination under the Equal Pay Act 1970 because she was paid less than male employees performing comparable work. Although the respondent admitted that the appellant was paid less in terms of wages than the male workers, it argued that, when factors of an overall remuneration package, such as sickness benefits and meal breaks, were taken into account, the appellant was treated as favorably as the men. The House of Lords of the UK reversed a lower court judgment accepting this argument and held that, under the Act, the appellant was entitled to parity in terms of pay without consideration of whether under the contract as a whole she was treated as favorably as male employees performing work of equal value.

Developed Countries↗
PubMed1988

Family Planning Regulations, 2 November 1988.

These Regulations provide the following: 1) women who give birth at a mature age are to be given one month's salary as a bonus or 30 additional days maternity leave; 2) cadres and staff who have a nonagricultural residence who give birth to a second child are required to pay the social expenses for raising the children and their monthly remuneration is to be reduced; and 3) women of child-bearing age who intend to work in Tianjin Province, China, are required to register with the relevant family planning authorities in Tianjin.

Asia↗
PubMed2002

Endodontics and new graduates: Part I, Practice vs training.

Surveys have demonstrated that many dentists, even the recently qualified, do not carry out endodontics using currently recommended materials and techniques. To assess the scale and nature of this finding among young graduates, a questionnaire was sent to all graduates from the mainland United Kingdom dental schools qualified for either one or four years. Widespread reduction in the number of radiographs taken and rubber dam use was found. A minority had adopted techniques and materials without published guidelines. It is suggested that alterations are required in undergraduate teaching, vocational training and the United Kingdom National Health Service remuneration system in order to improve the standard of endodontics in general practice.

Clinical Competence↗
PubMed2002

[A study on first-time stroke patients in a community use of home visiting assessment by public health nurses (PHNS)].

PURPOSE: The purpose of this study was to clarify the source of stroke registration, the type-specificity of incidence, and the degree of independence and caregiving status of stroke patients, as well as to explore the roles of PHNs, by analyzing information about stroke survivors in a community. METHODS: The subjects were of 323 patients, identified to have suffered a first-time stroke by PHNs' home visits etc., out of a total of 669 who were suspected of having had a stroke from 1983 to 1996 in Shinji-town, Shimane Prefecture. Data on the degree of independence and caregiving status obtained at the time of hospital discharge or after the acute period was over were classified. RESULTS: 1) Twenty-eight (8.7%) out of the 323 were registered through notifications from doctors/medical institutions, 47 (14.6%) through PHN activities, 84 (26.0%) through notice of death, 158 (48.8%) through National Health Insurance Remuneration Specification (NHIRS), and 6 (1.9%) through unknown sources. 2) The stroke incidence rate/1,000 person-year among Shinji-town residents aged 40 and over was 5.3 for males and 3.5 for females, and the type-specific incidence rate/1,000 person-years was 0.9 for cerebral hemorrhage, 3.1 for cerebral infarction, and 0.3 for subarachnoid hemorrhage. The average age at stroke occurrence was 72.1 years old. The 50% survival period was 71 months. 3) The degree of independence was confirmed for 166 disabled elderly: 64.5% of them were able to walk outdoors, 9.0% were capable of moving around inside the house but not of going outside, and 26.5% were bed-ridden. 4) Caregiving status was as follows: caregiving was not necessary for 56.9%. Sixty-nine point six percent of the remainder needed caregiving were living in their homes, and 30.4% were institutionalized or hospitalized. Of cases, where family members were caregivers, spouses were responsible in 58.3%, children or grandchildren in 10.4%, and daughters-in-law in 31.3%. CONCLUSION: The study shows that omission from stroke registration in a community could be minimized by PHNs' continued involvement on a long-term basis, confirming information from other sources through their home visits. PHNs may be required to provide mild case patients living independently with health management support for long period to prevent recurrence.

Aged↗
PubMed2003

Enhanced primary care. A rural perspective.

BACKGROUND: The Enhanced Primary Care (EPC) program is designed to promote better management of and improved health outcomes for people with chronic illness. Specific Medicare item numbers provide government funding to encourage general practitioners to take up health assessments, care plans and case conferences. AIM: We investigated elements of the EPC program from a rural general practice perspective. METHOD: Questionnaires summarising experience of EPC for patients and health care providers, undertaken over four weeks at three rural general practices, and observation. RESULTS: The EPC program assisted the management and coordination of care for patients with multidisciplinary care needs. General practitioners were generally positive about the EPC program. The main barrier was the extra time required. The main concern of allied health workers was the lack of appropriate remuneration for their participation. Patients were positive in their responses, but many appeared to lack the motivation and self management skills to take full advantage of the program. DISCUSSION: Strategies seeking to increase the uptake of EPC items need to address efficiency and accessibility, and funding for participating health professionals.

Chronic Disease↗
PubMed2003

[A battle of th health clubs in the Netherlands around 1840].

The discovery of a national inquiry into health funds in the 1840s gives cause to reconsider the traditional view on this subject. After a prosperous period under the guild regime commercial interests penetrated the health market. Its directors supposedly enriched themselves at the expense of both the insured and the professionals (general practitioners (gp's) and chemists). As things grew worse the government intervened and ordered an inquiry by a Select Committee. In reality things were slightly different. The debate on heath insurance was part and parcel of the pursuit of the medical profession to improve its standing. An alarming report on health funds by the Amsterdam medical commission spurred the Health Department to action. The national inquiry did not in fact corroborate the earlier report. In most parts of the Netherlands health insurance did not exist. In only two provinces - North and South Holland - taking out health insurance was an option and even there it was to a large extent in the cities. The three big cities - Amsterdam, Rotterdam and The Hague - accounted for 51.8 percent of all funds and as much as 72.2 percent of all persons insured. Nearly all complaints in the 1840s originated from gp's in Amsterdam. Only The Hague had the same experience i.e. infringements on private practice, enrichment by the fund governors etc. The complaints were not unlike those of the English club doctors at the end of the century. In both cities commercial health funds were important, while in Rotterdam gp's had very often been founding fathers. The author has tried to put the complaints into a wider perspective by comparing commercial funds with local clubs' and gp's own fund, the AZA, founded in 1847 to combat the disputed trend. Finally commercial funds have been compared with medical relief (number of patients and paid fees). The complaints about remuneration seem exaggerated as even AZA could not afford to pay higher fees. Commercialisation had only just started, but the new funds were more successful than the older clubs. AZA, however, proved to be even more successful. In close co-operation with poor law authorities a demarcation was introduced between medical relief and the working poor who had to take out a health insurance. AZA excluded the well-to-do from participating. Amsterdam developed a brand new health insurance policy in response to the threat of commercial funds. In the early twentieth century the story was repeated on a national level in response to proposals for compulsory sickness insurance.

Fitness Centers↗
PubMed2003

[Time pressure, inadequate wages, fear of unemployment. When work causes illness].

Changing demands made by the workplace may be associated with psychomental and socioemotional stresses. Underlying reasons involve work organization and specific work content, as also social relationships at the workplace, the remuneration situation, and the risks related to the occupational biography of the individual. Changes in the workplace-related risks necessitate further investigations into the work and performance process relevant to the individual case.

Fear↗