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PubMed2005

Impact of UK colorectal cancer screening pilot on primary care.

BACKGROUND: The UK Colorectal Cancer Screening Pilot has recently been completed to evaluate the feasibility of screening using the faecal occult blood test. Screening will be phased in over the next several years, and it is important to consider the impact on the NHS workforce. AIM: To determine the impact of the UK Colorectal Cancer Screening Pilot on primary care workload. DESIGN OF STUDY: A retrospective survey and prospective audit of general practice staff. SETTING: General practice. METHOD: Workload impact was assessed using a postal questionnaire and a prospective audit of activity in participating practices. Questionnaires were sent to practices that had been involved in the Pilot between 6 weeks and 1 year previously. They were sent to a random sample of 59 practices in Scotland and 60 practices in England between February 2001 and March 2002. Audit forms were sent prospectively to 60 practices involved in the Pilot between May 2001 and September 2002. RESULTS: Sixty-seven per cent of GPs, 82% of practice managers, 69% of practice nurses, and 70% of receptionists responded to the questionnaire. Of 60 practices contacted to take part in the workload audit, 38 returned completed 'workload impact audit' forms. Most practice staff indicated they spent 2% or less of their time during the screening period on Pilot-related activities. Forty per cent of GPs thought that a national colorectal cancer screening programme would substantially impact on the workload in primary care. However, there were variations by country: practice staff in Scotland were more likely to think that it would substantially impact on workload than practice staff in England (44.7% versus 26.6%). CONCLUSIONS: The surveys and audit demonstrate that the Pilot has had a discernible, albeit modest, impact on workload in primary care. Workload of particular significance to primary care personnel includes increases in paperwork, administration, and information provision to patients. The majority of primary care staff support the introduction of a colorectal cancer screening programme. However, there is a strong perception, particularly among GPs, that a national programme of faecal occult blood test screening will impact significantly on workload in primary care, and that primary care-based activities generated through screening should be adequately resourced and remunerated.

Aged↗
PubMed2004

[Modes of consultant employment in Israel].

BACKGROUND: One of the features of modern clinical practice is the shift of secondary care from hospitals to the community clinics. This phenomenon and the competition among health plans, has accelerated the development of secondary medicine at the community level, and increased the activity of outpatient clinics in acute-care hospitals. Consequently, many consultants are working in more than one setting within the framework of different modes of employment. AIMS: To examine the extent of consultants' employment in multiple organizational settings, and their modes of employment in each setting (i.e. weekly work hours, type of contract, mode of remuneration, and the division of time between community and hospital work). METHODS: A mail survey was conducted on a representative sample of 50% of consultants in six selected specialties: ophthalmology, dermatology, ear-nose-and-throat, gynecology, cardiology and general surgery (response rate 63%, n=890). RESULTS: Most (84%) of the consultants worked in more than one organizational setting, and more than 40% of them work in three or more settings. Nearly all the consultants (98%) work for a public sector employer in their primary job. Furthermore, in their secondary job, most consultants work for a public sector employer, usually a health fund (67% of them). When physicians' third jobs were examined, the high proportion (42%) of physicians engaged in private practice was prominent. The average number of weekly work hours of practice (including on-call hours) was 48 hours in the primary job and 63 hours in all jobs. The average duration of weekly work time was 52 hours not including on-call hours. CONCLUSIONS: The findings justify serious consideration of the proposal to reduce the number of jobs at which consultants work in order to improve both their clinical effectiveness and quality of work life.

Ambulatory Care↗
PubMed2004

National survey of endodontics in general dental practice in France.

The purpose of this paper was to gather both qualitative and quantitative information on endodontic treatments performed by French dental practitioners, and to identify the factors influencing the duration of endodontic procedures. A questionnaire was addressed in a two-rounds distribution to 2000 dentists selected by the quotas method in the whole country. A total of 790 (39.5%) questionnaires containing useful information were returned. The duration of endodontic treatment increases according to the number of roots to treat. The pulpal preoperative status has an influence on the duration of treatment, which is longer for a tooth with a necrotic pulp. Three variables strongly influence the duration of endodontic treatment: the number of patients attended per day, the number of appointments required for this treatment and the presence of a wage earner in the office. Continuing education also seems to be a variable having some influence on the duration of treatment. Financial considerations are also taken into account and there was general agreement that the current remuneration system of the French Health National Insurance is inadequate. Further, when one compares the total cost of an endodontic treatment with the fees fixed by the Health Insurance, it is clear that such procedures afford no positive financial return for a majority of practitioners. Moreover, the return becomes even more negative for teeth with a necrotic pulp. The findings presented in this study constitute the first stage of the medico-economic analysis concerning the endodontic practices in France. Prospective studies to gather precise information on the duration of endodontic treatments and a cost-analysis of endodontic practices could assist in the decision making process for practitioners or for the policy makers in the formulation of policies regarding application and reimbursement of endodontic treatment.

Appointments and Schedules↗
PubMed2005

Is there any solution to the "brain drain" of health professionals and knowledge from Africa?

African public health care systems suffer from significant "brain drain" of its health care professionals and knowledge as health workers migrate to wealthier countries such as Australia, Canada, USA, and the United Kingdom. Knowledge generated on the continent is not readily accessible to potential users on the continent. In this paper, the brain drain is defined as both a loss of health workers (hard brain drain) and unavailability of research results to users in Africa (soft brain drain). The "pull" factors of "hard brain drain" include better remuneration and working conditions, possible job satisfaction, and prospects for further education, whereas the "push" factors include a lack of better working conditions including promotion opportunities and career advancement. There is also a lack of essential equipment and non-availability or limited availability of specialist training programs on the continent. The causes of "soft brain drain" include lack of visibility of research results in African journals, better prospects for promotion in academic medicine when a publication has occurred in a northern high impact journal, and probably a cultural limitation because many things of foreign origin are considered superior. Advocates are increasingly discussing not just the pull factors but also the "grab" factors emanating from the developed nations. In order to control or manage the outflow of vital human resources from the developing nations to the developed ones, various possible solutions have been discussed. The moral regard to this issue cannot be under-recognized. However, the dilemma is how to balance personal autonomy, right to economic prosperity, right to personal professional development, and the expectations of the public in relation to adequate public health care services in the developing nations.

Africa↗
PubMed2004

Acceptance and completion of hepatitis B vaccination among drug users in New York City.

Hepatitis B (HBV) vaccination rates remain low among drug users. We examined correlates of vaccine acceptance and completion in two ongoing prospective studies of young injecting and non-injecting drug users in New York City. Street recruited drug users were enrolled at one of two neighbourhood locations (Harlem and the Bronx) between 2000 and 2004 and completed risk behaviour questionnaires and HBV testing. Free HBV vaccination was offered. Among 1117 participants, 26.1% (275) had a previous HBV infection, 57.9% (610) were susceptible to HBV, and 16.0% (169) had serological evidence of previous vaccination. Of the 610 participants susceptible to HBV, 466 (76.4%) returned for their results and were offered vaccination; 53.9% (251) received at least one dose of the vaccine (acceptors). Correlates of vaccine acceptance included older age, public assistance as main income source, and being recruited in the Bronx. Daily crack users were significantly less likely to initiate the vaccine series. Among 240 vaccine acceptors, 98 (40.8%) completed all three doses. Daily injectors, Hispanics, and those recruited in Harlem were less likely to complete the vaccination series. HBV vaccination acceptance among drug users seems likely in programmes that are convenient and offer remuneration; however, extended efforts are needed to improve series completion.

Adult↗
PubMed2002

The Bioethics Convention of the Council of Europe and organ sharing for transplant recipients in Scandinavia.

Even though organ transplantation is often life saving, the lack of donor organs is limiting the number of transplantation procedures. In small countries, like the Scandinavian countries, the small population level highlights this problem of organ availability which is further complicated by the fact that the utilisation of available organs may be prevented by histoincompatibility between the host and donor. This problem can only be solved by sharing both medical information and organs across countries. In Scandinavia, an organ sharing program (Scandiatransplant) was initiated between Denmark, Finland, Iceland, Norway and Sweden in the late 1960's long before the establishment of European Economic Area and the expansion of the European Union in Northern Europe. Even though trade in human organs is prohibited by international conventions, medical procedures and services that are associated with transplant activities are such services whose "free movement" within the Union is guaranteed by the Convention of Rome. These services can thus be offered across the national borders for remuneration. The potential impact of the conventions of the Council of Europe on transplantation services and organ sharing programs within European Union will be discussed.

Bioethics↗
PubMed2005

Becoming a GP--a qualitative study of the career interests of medical students.

AIM: Only a minority of Australian graduates are interested in careers in general practice. The factors influencing medical students toward general practice as a career choice are poorly understood, even though this is important to the makeup of the medical workforce. METHODS: We ran 10 focus groups involving 82 first and final year medical students from three Australian medical schools in 2002, and analysed factors influencing participants' interest in working in general practice. RESULTS: About half the students were interested in general practice. Attractive factors were: the nature of the work (including its diversity), continuity of care, community context, and working conditions (including flexibility of training and work, availability of part time work and portability of qualifications). Negative factors included: the breadth of knowledge needed, boring work (in urban general practice), having to run a business, and working conditions (including relatively poor remuneration, overwork in rural general practice, and poor status of general practitioners). Some students were strongly influenced by negative attitudes of the GPs they were taught by, deciding against general practice as a career. DISCUSSION: Medical educators and GPs should be aware of this important influence.

Adolescent↗
PubMed1994

Testing the limits of freedom of contract: the commercialization of reproductive materials and services.

This article examines the cases for and against commercializing, or "commodifying," reproductive materials and services. Using a supply/demand third-party framework, three basic scenarios in which commercial-exchange relationships may be possible--exchange of gametes and zygotes, exchange of gestational services, and exchange of fetal material--and the major parties of interest, or stakeholders, are identified. The study sketches the liberal, essentialist, and radical contingency theories that shape the debate over the commercialization of reproductive materials and services. The article then attempts to derive some basic governing principles that reflect as much common ground as possible amongst these various normative perspectives, while recognizing that complete reconciliation is impossible. Taken together, these principles are designed to reflect a strategy of "constrained commodification," where commercialization or commodification, that is, financial remuneration, plays a relatively neutral role in the utilization of reproductive materials and services. In light of these principles, the article concludes by sketching legal and regulatory regimes with respect to the exchange of gametes and zygotes, gestational services, and fetal tissue.

Aborted Fetus↗
PubMed2003

Pilot study on the factors that influence learning by general practice registrars in central Australia.

INTRODUCTION: To counter a medical workforce shortage in rural and remote areas of Australia an increasing number of general practitioners are being trained in rural and remote areas. General practice (GP) registrars train in general practice as working apprentices alongside GP supervisors. GP registrars are allocated a training advisor to oversee their progress throughout their training. Central Australian GP registrars expressed concern to their training advisor regarding certain work partnerships with their GP supervisors. The study was carried out in response to these concerns, which were raised during a shortage of GPs in the area. The aim of the study was to explore factors in the interaction between GP registrars and GP supervisors in the context of their practices that impact on the quality of GP registrar learning in Central Australia. METHOD: A qualitative research method was used to explore the subtleties and issues in relationships between GP registrars, their GP supervisors and their practices. The interview schedule comprised pairs of polarised, provocative statements to generate discussion. Topics for the interview schedule were derived from the data from training advisor visits and the literature. GP registrars in Central Australia who had completed at least one six-month term in general practice were eligible for the study. Five female GP registrars participated in the study. Interviews were recorded, transcribed and checked by the participants before the interview material became the research record. RESULTS: The interview schedule generated considerable discussion as planned. The structures that determine GP income were seen as a barrier to GP registrar learning in Central Australia. The registrars reported that the fee-for-service model prevented them capitalising on learning opportunities both inside and outside their designated general practice. The GP registrars considered their training was compromised by the need to provide clinical service during a time of workforce shortage. Adaptation to a practice was seen as an important skill for GP registrars to learn, providing this did not compromise a registrar's own ethical and professional values. Learning was optimised by agreement between GP registrars and GP supervisors on the teaching subjects, and a mix of opportunistic and planned teaching sessions. Geographical isolation was perceived to have had a significant negative impact on GP registrar learning but one GP registrar discussed how this could be turned into a positive factor. CONCLUSION: GP registrars reported learning best by providing a clinical service with ready access to a supportive GP supervisor. Workforce pressures in Central Australia at the time of this pilot study reduced the GP supervisors' ability to support GP registrars, especially in a fee-for-service model of health care. GP registrars should be placed in practices where they will receive experience, training and education rather than be allocated to areas of workforce shortage. Changes to the remuneration system for GP registrars and GP supervisors could be considered to enable GP registrars to capitalise on the learning opportunities in remote clinical practice.

Journal Article↗
PubMed2005

Availability, safety and quality of blood for transfusion in the Americas.

OBJECTIVES: This article has two objectives: (1) to present for countries and territories of the Region of the Americas data on the number of blood donations, proportion of voluntary blood donors versus remunerated blood donors, coverage of screening for infectious agents, and separation of donated blood into its components and (2) to explore the relationships of those characteristics with economic and organisational factors in the countries and territories. METHODS: We carried out comparative analyses using population and health information gathered annually by the Pan American Health Organization (PAHO) from national health officials from the countries in the Americas, as well as economic information (gross national product (GNP) per capita) obtained from publications of the World Bank. RESULTS: There is a direct correlation between the availability of blood for transfusion and GNP per capita. Seven countries with a GNP per capita above US dollar 10,000 per year account for 38% of the Regional population but 68% of the Regional blood donations. Voluntary blood donation is more common in the countries with better blood availability. There is no association between GNP per capita and coverage of screening for infectious agents. Nevertheless, of the six countries with a GNP per capita below US dollar 1,000, only one of the six screens all units for human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B surface antigen (HBsAg). Countries with a higher proportion of voluntary blood donors tend to have lower prevalence rates of infectious markers. Separation of blood into its components is also more common in countries with higher blood donation rates. CONCLUSIONS: The availability, safety and quality of blood for transfusion in the Americas needs to be improved. As part of that effort, national policies and strategies must be put into place so that the resources already allocated for blood services are better utilised.

Americas↗
PubMed2004

General practitioners' perceptions of after hours primary medical care services: a Toowoomba, Queensland, Australia study.

INTRODUCTION: This article reports on a project, undertaken in 2002 in the regional city of Toowoomba, Queensland, Australia, that investigated the viability of establishing an after-hours primary medical care (AHPMC) service. OBJECTIVES: To ascertain GPs' perceptions of the adequacy of AHPMC services in Toowoomba. DESIGN: Thirty GPs were randomly selected to participate in face-to-face interviews using a semi-structured interview tool. SETTING: Toowoomba, Australia is the largest inland non-capital city in Australia. It is located approximately 130 km west of Brisbane, the State capital city and is a referral centre for patients from the rural and remote communities of south-west Queensland. PARTICIPANTS: 15 male and 15 female GPs. RESULTS: While the majority of participants believed the current provision of AHPMC in Toowoomba was adequate, they stated that the provision of AHPMC services was onerous and, given a choice, they would prefer to refer all patients seeking care between 2200 and 0800 hours to an Emergency Department (ED). Similar to GPs who work in rural and remote areas of Australia, they believed that AHPMC work was poorly remunerated, had an adverse effect on their lifestyle and could endanger their personal and their patient's safety. CONCLUSION: The findings of this study confirm previous studies into the perceptions of GPs to the provision of AHPMC in a regional city. Additionally, while the GPs in Toowoomba have the options of referring after-hours patients to an ED and being part of a large GP after hours cooperative, their opinions on after-hours work did not differ significantly from those expressed by GPs working in rural and remote areas of Australia. The GPs in this study, given the option, would prefer not to undertake an AHMPC service provision between 2200 and 0800 and many had chosen not to do so, instead directing their patients at this time to one of the two EDs located in Toowoomba.

Journal Article↗
PubMed1992

[Quality assurance in ambulatory care. Viewpoint of the forensic expert for concentrated action in public health].

FUNDAMENTALS: Assuring the quality of medical care is a self-imposed obligation on the part of the profession and, at the same time, a legal obligation. MAIN TOPICS: On the way to implementing this requirement, the following points must be taken into account: the measurability of the quality of medical care, establishment of the quality of structure, treatment and results, aids for the determination and documentation, remuneration, and the motivation for implementing quality control. CONCLUSIONS: A further development of present day approaches to quality assurance resulting in returning to the physician more responsibility while putting on him the onus of proof, would be desirable.

Expert Testimony↗
PubMed2005

Perspectives of paid whole and plasma donation.

Although payment of blood donors is rejected by the WHO, the FDA, the EU, and the Red Cross (RC), in Germany, monetary compensation of expenses is permitted not only for plasmapheresis but also for whole blood donation. The structure and organisation of the institutions ensuring the blood supply in Germany and the pertaining aspects of blood safety will be discussed. Data reported to the health authorities show that the frequency of transfusion-transmitted infection markers in the German donor population is low and that only very few infections have been transmitted through blood. This is underlined by a detailed analysis of the paid donor population of a small university blood service (UBS). The analysis documents a very stable and reliable cohort of predominantly repeat donors. Unpaid RC donors of blood units transfused to patients at the university hospital of Marburg showed a sixteen-times higher sero-conversion rate than those of the UBS (p < 0.0001). However, in a survey, 77% of the paid donors denied continuation of blood donation in the event of payment being stopped. Therefore non-remuneration would result in acute blood supply shortages. Since increased blood shortages are to be expected anyway in the near future, all measures improving the supply of safe blood, including monetary compensation, should be objectively discussed without prejudice.

Blood Donors↗
PubMed2005

Taking a closer look at blood donation in Latin America.

Shortages and unsafe blood still threaten the health of millions of individuals who need blood transfusions in Latin America. There are many demographic and socio-economical factors contributing to this situation. Poverty, high prevalence of infectious diseases, fragmented blood systems, reliance on replacement donors and hospital-based systems are undermining efforts to promote and retain voluntary non-remunerated blood donors (VNRBD) and are endangering the blood supply. Some economic factors seem unsurmountable in countries such as Haiti, Guatemala and Honduras, where the cost of processing a unit of donated blood exceeds the annual per capita budget allocation to health care. However, many countries which have chosen to coordinate their efforts nationally are able to attract 15 times more vnrbd. Working cooperatively with non-governmental agencies such as the Red Cross are also yielding higher rates of voluntary blood donors and fewer paid donors.

Blood Donors↗
PubMed2005

Donor management in South-East Asia region (SEAR).

Quality management of a BTS starts with safe donor recruitment and donor care. In the South-East Asia region (SEAR) almost all countries except Thailand depend heavily on replacement of blood from relatives and friends. Most of these countries except Bangla Desh have ruled out the paid-donor system; however in the guise of replacement donation it still exists. Lack of resources, lack of professional management, myths and misconceptions arising from cultural and social differences form a barrier to blood donation. Most of the countries still do not have a National Blood Policy and/or a well planned blood programme. Besides recruitment, the donor screening and donor management are also not well addressed. The donors are mainly males of 20-35 years who come from the middle class of the society. Only 3-6 % of females donate blood. Most of the donors donate once in a lifetime as there is no emphasis on retention programmes. Only 5-10 % are repeat donors. The autologous transfusions are not widely practised. However, insistence on directed donors has increased. The prevalence of transfusion-transmissible infections in the region is variable; HIV 0-1.6 %, HBV 0.06-8.5 %, HCV 1.2-3 %. Training of staff and volunteers involved in the programme has started. Countries such as India and Sri Lanka are introducing NBP and moving towards reorganisation of their blood programme. All countries have now realised a need for regulation and implementation of a quality system as well as increased their efforts towards donor recruitment and retention. To improve the safety of blood supply, all are trying to phase out the replacement system and move towards 100 % voluntary non- remunerated regular blood donation. The aim of the presentation is to highlight the problems encountered as well as strategies used in making adequate and safe blood available.

Asia, Southeastern↗
PubMed1992

Capitation: a service by another name.

Fee for service and capitation systems are usually regarded as different methods of medical remuneration, however, they can be seen to differ mainly in the degree to which they 'bundle' or 'package' medical services. A capitation system for general practice services in Australia could be established by the creation of a Medicare item and benefit for a year's general practice care. This would allow doctors to assess the benefits of capitation without a total and potentially traumatic commitment, and may encourage innovation in the efficient delivery of primary health care.

Australia↗
PubMed2005

[The list patient scheme and the growth insurance expenditure in general practice].

BACKGROUND: Fee-for-item payments, mainly from the National Insurance Administration, are the main source of remuneration for primary care physicians in Norway. The aim of the present study was to describe the development in the National Insurance Administration's expenditure for primary physician services before and after the introduction of a list patient scheme in 2001. MATERIAL AND METHODS: The analyses were performed on data from the National Insurance Administration and data on the number of physician in relation to population from Statistics Norway. RESULTS: During the period 1998-2003, expenditure increased by 84%, from NOK 1.37 billion to NOK 2.52 billion. The main finding is that nearly all the increase can be explained by increases in the number of physicians, population size and the level of fees. INTERPRETATION: One interpretation of our findings is that to a large extent the National Insurance Administration's expenditure on primary physician services can be controlled by regulating the number of physicians and the level of fees.

Family Practice↗
PubMed2005

European community legislation concerning schools of specialisation in orthodontics: the inexplicable inertia of Italy--contradictions and open issues.

Orthodontics was the first discipline to be acknowledged as such within the field of dentistry, initially in the USA and subsequently in Europe. The structural changes that led to the birth of the European Union (EU) laid the foundations for the free circulation of professions and services. Nevertheless a deep discrepancy in the quality of training of practitioners from different countries became apparent. It was necessary to address this issue and regulate the training process in order to guarantee a degree of uniformity. Up to this time only the duration of the School of Specialisation in Orthodontics has been set at a minimum of three years. While moving towards an increasing degree of integration of the various EU countries, it becomes paramount to be able to establish a School of Specialisation in Orthodontics with high academic standards based on the Erasmus Programme and above all to be able to award a specialisation degree which is acknowledged first of all in the country where it is issued and also on a wider European level. Freedom of circulation of intellectual activities requires the formal acknowledgement of a qualification, namely the Specialisation in Orthodontics. Also to that end, EFOSA (European Federation of Specialists in Orthodontics) was founded. Furthermore the European Community has, in the meantime, ruled that medical trainees should be remunerated for their work. Dentistry and its specialisations should not follow the model of Medicine given that the two are completely distinct, but many believe that the duration of the School of Specialisation in Orthodontics has to be set as the same as the medical specialisations.

Education, Dental, Graduate↗