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PubMed1999

Rationing health care in France.

Since the Plan Juppé (1995), many facets of the French health care system have been the target of new legislative measures. This paper discusses the main features of the financing and provision of health care services, and focuses on issues related to priority setting and rationing. For more than 20 years, successive but systematic changes have been implemented. Most changes and measures affected the demand and supply of health care services, as well as their prices. Attempts to control demand focused mainly on the increase of user charges (ambulatory care as well as the hospital sector). Control over the volume of supply consisted, for the most part, in limiting the number of health professionals and restricting hospital beds. As far as payment is concerned, the French public authorities had set a general system of administrative prices (negotiated fees for private practice physicians, pharmaceuticals and other medical goods) and implemented global budgets for public hospitals. Among the new features designed in 1996, which target both cost-containment and quality of care, we emphasise the Parliament's involvement in setting national expenditure targets for sickness funds, the experimentation with a gatekeeper-like system (médecin référent), the development of practice guidelines and quality controls through the accreditation of hospitals. As the 1998 Eurobarometer Survey clearly shows, none of these reforms is easy to implement; they will take time to be accepted and will need physicians' support to succeed.

Cost Control↗
PubMed1998

The VHL tumour-suppressor gene paradigm.

The VHL tumour-suppressor gene (TSG) has a critical 'gatekeeper' role in regulating growth and differentiation of human kidney cells, and inactivation of the VHL gene is the most frequent genetic event in human kidney cancer. There are many similarities between the genetics of the VHL and retinoblastoma TSGs, but the VHL tumourigenesis model is more complex. Here, we examine the current knowledge of the genetics and functional aspects of the VHL TSG, and emphasize how the VHL gene provides a paradigm that illustrates many aspects of TSG biology.

Genes, Tumor Suppressor↗
PubMed1997

Patients' opinions regarding direct access to dermatologic specialty care.

Many factors such as cost have been used by managed care systems to limit patient access to specialty care, including dermatology. To date, however, patients' opinions regarding these decisions have not been analyzed. The purpose of the study was to survey patient opinions regarding the efficacy, costs, and desirability of gatekeeper-mediated versus direct access to dermatologic specialty care. One hundred fifteen of 150 consecutive patients who were seen in an outpatient dermatology clinic completed an anonymous survey concerning their current visit. They were asked about referral to the dermatologist by other physicians, number of prior physician visits, and efficacy of therapies received. Patients rated their level of satisfaction with generalist versus specialist care for their condition and evaluated the importance of direct access to dermatologic specialty care. Thirty-nine percent of respondents (42 of 108) were on their first visit to the dermatologist for their current condition. One half of respondents (57 of 115) had previously seen another physician for this condition. Thirty percent (34 of 115) had been referred to the dermatologist by another physician, most often a family practitioner or internist. Two thirds (38 of 57) of those seen by a previous physician had received therapy from that physician, but only one third (12 of 35) believed it to have been of any benefit. Twenty-three percent (11 of 47) claimed to have incurred more than five visits to the other physician before seeing the dermatologist. Twenty-four percent of patients (12 of 50) were "very satisfied" with the previous physician's care compared with 89% (100 of 112) with the dermatologist's care. Only 6% of respondents (7 of 122) believed a generalist could adequately treat their skin disease. Eighty-seven percent (100 of 115) described direct access to dermatology as being "very important" to their health care. The results of this study suggest that many patients may prefer dermatologic specialists over generalists as primary caregivers for diseases of the skin. They may favor direct access to dermatologic specialty care for its efficacy and for cost and time savings.

Adolescent↗
PubMed1999

Patients can accurately identify when they have a dermatologic condition.

The use of "gatekeepers" may be rational when patients do not know what specialist to see for their condition. Using representative data on outpatient practice in the United States, we tested the hypothesis that when patients believe they have a skin condition, they have a dermatologic disease. At least 95% of visits for skin symptoms are associated with dermatologic diagnoses. Patients who believe they have skin conditions do have dermatologic diseases and are able to choose the appropriate specialist.

Humans↗
PubMed1996

Universal newborn screening for hearing loss: ideal vs. reality and the role of otolaryngologists.

In 1993 the National Institutes of Health Consensus Statement, Early Identification of Hearing Impairment in Infants and Young Children, recommended "universal screening for hearing impairment prior to three months of age." However, the decision to invoke screening programs that include all newborns remains highly controversial, even though such programs now exist in at least 60 hospitals in 18 states. Unfortunately, otolaryngologists in the United States have not been actively involved in this ongoing debate, despite the role of those in our specialty as "gatekeepers" of hearing loss in patients of all ages. In relation to identification of hearing loss in the neonatal period, we have abrogated our responsibility to other health care professionals. Otolaryngologists, this is your "wake up call."

Attitude of Health Personnel↗
PubMed1998

Effect of a large managed care program on emergency department use: results from the CHAMPUS reform initiative evaluation.

STUDY OBJECTIVE: To determine the effect of the CHAMPUS Reform Initiative (CRI) on emergency department use and charges, and to ascertain whether any reductions were concentrated among repeat users of the ED, those with less serious ED diagnoses, or those with selected chronic medical conditions. METHODS: Participants were approximately 1.2 million beneficiaries of the Civilian Health and Medical Program of Uniformed Services (CHAMPUS) residing within either 11 military hospital catchment areas in California and Hawaii ("demonstration areas") or 11 matched control areas in other parts of the United States. Under CRI, participants were offered a choice of the standard CHAMPUS indemnity plan, a Preferred Provider Organization-type plan, or a network-model Health Maintenance Organization plan. Beneficiaries were encouraged to use alternatives to the ED for nonemergency conditions. Visits to civilian EDs during two 12-month periods, before and after institution of CRI, were compared. RESULTS: Under CRI, the number of CHAMPUS ED visits decreased by approximately 40% relative to the control, and allowed charges fell by almost 50%. Relative reductions in ED use under CRI were seen among both frequent and infrequent users of the ED. ED case-mix severity increased modestly relative to control (+3.5% versus +.9%). ED use among patients with diabetes, hypertension, and asthma fell sharply in the demonstration areas (by 14% to 41%) but rose in control areas (by 4% to 9%). CONCLUSION: In one of the largest managed care demonstrations ever conducted, a nonintrusive use management program and improved access to outpatient care appeared to reduce ED use, allowed charges, and costs to the government. Reductions in ED use were concentrated to some extent among repeat users and patients with less severe illnesses and were effected without capitation of provider groups or strict gatekeeping requirements.

California↗
PubMed2001

Enhanced activation of rhesus T cells by vectors encoding a triad of costimulatory molecules (B7-1, ICAM-1, LFA-3).

Since the rhesus is often used as a "gatekeeper" model for the evaluation of malaria and simian immunodeficiency virus (SIV)/HIV vaccines, the identification of strategies to enhance the activation of rhesus T cells would potentially aid in the generation of more potent vaccines directed against these infectious agents. Several molecules normally found on the surface of professional human APCs are capable of providing the second signals critical for T cell activation: B7-1 (CD80), ICAM-1 (CD54), and LFA-3 (CD58). With the exception of B7, T cell costimulatory molecules in the rhesus have not been identified. We have recently designed and characterized both recombinant vaccinia and recombinant avipox vectors containing the transgenes for a triad of human T cell costimulatory molecules (B7-1, ICAM-1, LFA-3; designated TRICOM). Here, we demonstrate the enhanced activation of rhesus T cells stimulated with rhesus APCs infected with TRICOM vectors in the presence of signal 1. Infection with TRICOM vectors led to significant improvement of APC capabilities in terms of reduction of the amount of signal 1 needed to activate naive T cells, and reduction in the amount of APCs required to activate T cells using a constant amount of signal 1. Antibody blocking studies demonstrated that each of the three costimulatory molecule transgenes contributed to the enhanced proliferation of T cells. TRICOM-enhanced T cell activation was shown to correspond to increases in type 1 cytokines and a reduced level of apoptosis. TRICOM-infected autologous B cells from rhesus immunized with either an SIV vaccine or a malaria vaccine stimulated significantly greater levels of IFN-gamma in response to specific peptide than stimulation with uninfected autologous B cells or B cells infected with wild-type vector. The ability to augment immune responses using poxvirus-based vaccines containing multiple costimulatory molecule transgenes can now be addressed in the rhesus macaque model.

AIDS Vaccines↗
PubMed1999

The significance of 'hierarchy' in a research project on adoption and adaptation.

In the course of phenomenological research project focusing on the midwife's care of the mother who relinquishes her baby for adoption, hierarchy emerged repeatedly as a significant theme. This concept manifested itself both methodologically as well as thematically. In methodological terms, hierarchy first became apparent during the planning phase in the selection of the research design: at this point it took the form of the distinction between quantitative and qualitative research design. In the course of applying for research access the same attitudes re-emerged in the gatekeepers' responses to the research design which had been chose. Later, during the field work, hierarchy appeared in the course of the interviews, in the form of the unequal balance of power between the interviewer and the informant. Specific tactics were required to overcome the likelihood of hierarchy affecting the data at this stage. Eventually this concept was raised by the informants, who included both relinquishing mothers an midwives, and became a major theme. The informants' use of hierarchy to explain the unselfishness of relinquishment proved to be one of a number of strategies which facilitated coping either with the experience of relinquishment or with caring for a women going through that experience. The conclusion which emerges is that hierarchy features in many aspects of life. While it may be beneficial when applied to certain situations to facilitate coping, in other circumstances it may be less than positive.

Adaptation, Psychological↗
PubMed2003

ORS is never enough: physician rationales for altering standard treatment guidelines when managing childhood diarrhoea in Thailand.

This study explores Thai physicians' rationales about their prescribing practices for treating childhood diarrhoea within the public hospital system in central Thailand. Presented first are findings of a prospective clinical audit and observations of 424 cases treated by 38 physicians used to estimate the prevalence of sub-optimal prescribing practices according to Thai government and WHO treatment guidelines. Second, qualitative interview data are used to identify individual, inter-personal, socio-cultural and organisational factors influencing physicians' case management practices. Importantly, we illustrate how physicians negotiate between competing priorities, such as perceived pressure by caretakers to over-prescribe for their child and the requirement of health authorities that physicians in the public health system act as health resource gatekeepers. The rationales offered by Thai physicians for adhering or not adhering to standard treatment guidelines for childhood diarrhoea are contextualised in the light of current clinical, ethical and philosophical debates about evidence-based guidelines. We argue that differing views about clinical autonomy, definitions of optimal care and optimal efficiency, and tensions between patient-oriented and community-wide health objectives determine how standard practice guidelines for childhood diarrhoea in Thailand are implemented.

Child, Preschool↗
PubMed1997

Staying single in the 1990s: single-handed practitioners in the new National Health Service.

The U.K. health care system is organised around independent medical practitioners who work in community settings and act as gatekeepers for acute health interventions. Recent developments in U.K. health policy have revolutionised the environment within which all general medical practitioners (GPs) operate. The last five years in the U.K. have seen the most fundamental health service reforms since the inception of the National Health Service (NHS) in 1946: namely, the development of the internal market, an increasing emphasis on primary health care, and changes to the GP Contract in 1990. Single-handed GPs (practitioners not in partnership with other GPs) traditionally work in the most deprived areas with the greatest health and social problems. The current restructuring and the subsequent organisational and policy initiatives present particular problems for single-handed practitioners. How single-handed practitioners respond to the reforms raises particularly important debates that are significant both for themselves and for the populations they serve. Drawing upon a range of sources, this paper discusses three central issues that emerge. First, how do single-handed practices relate to the more managerial role envisaged for authorities responsible for supporting primary health care? Second, given the development of the internal market, how do single-handed practices fare in influencing local policy and priority setting? Third, to what extent can single-handed practitioners take advantage of the opportunities to hold their own budgets? Overall, in the context of recent U.K. health care reforms, what is the future for "staying single in the 1990s"?

Family Practice↗
PubMed1998

Mechanisms of trafficking in axons and dendrites: implications for development and neurodegeneration.

In the area of routing and sorting of dendritic traffic, the current phenomenological data beg questions about the cellular mechanisms utilized not only to transport material but also to modulate activity in a process, even apoptosis. To aid in formulating testable hypotheses, many plausible models are developed here and linked with some of the preliminary data that supports them. We first assume that in long dendrites the sorting of membranous proteins into transport vesicles also involves the linkage of motor proteins to the vesicles. Second, we assume that the cytoskeleton in dendrites is altered from the cytoskeleton in axons and the cell body. Viral glycoproteins, MAP2 and specific mRNA sorting into dendrites provide the simplest models for analyzing vesicular, cytoskeletal and RNA sorting. In the case of viral glycoproteins, initial sorting appears to occur at the Golgi but additional routing steps involve further complexities that could best be served by an additional sorting step at the junction of the cell body and the process. Transport of the specialized cytoskeletal proteins and specific mRNAs as well as vesicular material could be controlled by a similar gatekeeper at the mouth of a process. Studies of the microtubule-organelle motor complex, regulation of microtubule-based motility by microtubule-associated proteins, and slow axonal transport all provide insights into important aspects of the routing and sorting. These processes are in turn controlled by extracellular signals such as those generated by matrix molecules or their hydrolysis products in the case of amyloid precursor protein (APP). Routing and sorting mechanisms may be central to the development of Alzheimer's disease in view of evidence that APP processing is affected, transport is disturbed, and intracellular vesicles (early endosomes) hypertrophied. Further it is possible that routing mechanisms play a role in cell-cell interactions as, for example, the possibility that pathogenic/cellular stress signals may be passed along circuits transsynaptically.

Animals↗
PubMed2003

Keeping the lid on: a century of drug regulation and control.

Since the early 1900s, national and international drug control legislation has acted as a key site of contention between important societal actors. Physicians and pharmacists, regulators and drug companies, patients and addicts, and researchers and pharmacologists all attempted to influence formulation and interpretation of the rules that regulate access to addicting but medically useful substances. The 1970 Controlled Substances Act (CSA) consolidated and rationalized previous US domestic legislation and paid careful attention to the international aspects of the issue. Yet the CSA also incorporated long-standing fundamental disputes about who would act as gatekeepers, what criteria would be employed in regulatory decisions, and the basic goals of drug control legislation. Rather than view the CSA as a beginning or an end, it is better conceived as a major milepost in a century-long odyssey of maneuvering among interested parties for advantage in a complex regulatory environment. Instead of providing a definitive authoritative structure to which all parties must adhere, the CSA has served as a vehicle for discernment and continuous renegotiation of essential concepts such as "abuse liability".

Drug Industry↗
PubMed2000

Economic aspect of health care systems. Advantage and disadvantage incentives in different systems.

European health care delivery systems illustrate the effect of economic incentives on health care delivery. Each country faces the issue of trying to balance the desire for economic efficiency with comprehensive, quality medical care. Without careful use of economic incentives achievable with central control, one gets to pick only two of the three desired goods--high quality, low cost, and comprehensive coverage. In the United States, payment approaches for health care have been undergoing tremendous changes since the early 1980s. These changes have escalated during the 1990s. The basic approach for reimbursing hospital care has been completely restructured by many payers for care, and payment approaches for physicians and long-term care providers also are being restructured. Financing approaches vary from provider to provider and payer to payer, and financing approaches will continue to evolve over time. In the traditional fee-for-service reimbursement system, the incentive to physicians is to do more because more services lead to more revenue. The use of incentives to influence health care practitioners' behavior is common. Incentives are generally financial in nature and expose health care providers to some risk or reward for certain patterns of behavior. Some common incentives used in managed care include capitation payment, in which a physician is paid a fixed fee, regardless of the number of services administered; bonus distribution; and withhold accounts, through which a practitioner stands to gain or lose some amount of money for overuse or underuse of medical resources against budget. In many countries, a strengthening of the position of primary care providers can be observed: Finland, Germany, Greece, Italy, the Netherlands, Norway, Sweden, the United Kingdom, and now the United States. General practitioners are assumed to function as a gatekeeper to second-line care, such as specialist care, prescription drugs, and hospital care. A further step is to give the primary care providers financial responsibility for the costs of the follow-up care provided by others to their patients. By examining the health care systems of other countries, the potential negative impact of such an approach on the use of specialists can be seen. The negative impact of these approaches on patient care is clear when dermatologists and general practitioners are compared in the delivery of dermatologic health care.

Delivery of Health Care↗
PubMed2000

The emerging role of physician assistants in the delivery of dermatologic health care.

The NAMCS provides a wealth of information on use of PAs in all practices, including dermatology. Two important points regarding the NAMCS and SDPA data are addressed here: the number of visits to PAs for dermatologic symptoms and the expected growth of PA use in dermatologists' offices. Dermatologic symptoms were evaluated frequently by PAs, accounting for 14% of PA visits. These statistics do not address the number of referrals those PAs made to dermatologists. Perhaps PAs as a group should be targeted for increased dermatologic education, particularly stressing the need for appropriate referral to a dermatologist. PAs could increase the number of dermatology referrals from primary care offices with improved understanding of the importance of the dermatologist in the management of patients' overall skin health. At projected growth rates, the number of PAs employed by dermatologists should exceed 500 by the end of 2000. Most of this growth has been in private practices and rarely in HMOs or in large multispecialty clinics. There are a number of reasons for this growth, as follows: A PA may help reduce the patient load on the dermatologist, especially with sameday appointments and drop-ins. Some dermatologists are moving away from clinical dermatology into cosmetics, which not only leaves a vacuum in clinical dermatology, but also creates job opportunities for PAs in cosmetic dermatology. Regarding managed care growth, PAs can have a positive impact on the problem of having to see more patients for less money. PAs are cost-effective. In the 1998 SDPA survey, the ratio of billings generated (production) to gross income for the average dermatology PA ranged from 3:1 to 6:1. Even with inexperienced PAs new to dermatology, this ratio was usually at least 2:1 at the end of the first year. PAs can cover satellite offices, allowing for practice expansion. Effective with the new Medicare laws of January 1, 1998, PAs can now see new Medicare patients or Medicare patients with new conditions without the physician being on site, opening up the possibility for satellite offices in remote areas. Just as dermatologists may move toward specialization in surgery, cosmetics, or medical dermatology, PAs may do the same, filling a niche in a particular practice. As in other specialties, patient acceptance of seeing dermatology PAs has not been a significant problem. Continued access to the dermatologist remains unfettered, but, over time, many patients become willing to see either. Are PAs likely to become future competitors of dermatologists? Genuinely concerned dermatologists worry that a dermatology-trained PA will become part of a gatekeeper system that impedes patient access to dermatologists. This is not happening and is not at all likely to become a trend, for a number of reasons. First, primary care cannot compete with dermatology practices in remuneration for PAs. Just as financial benefits in high-production specialty practices entice physicians, the same benefits entice PAs as well. Second, according to member surveys of the SDPA, virtually 100% of fellow members work with dermatologists. Although PAs can work in any type of practice and evaluate dermatologic symptoms just as a general practitioner would, PAs who specialize in dermatology primarily practice with dermatologists, a collegial association most PAs seek out. PAs have steadfastly maintained their dependent, noncompetitive relationship with physicians and would not have it any other way. Although PAs see a good number of patients (2.8 million) with dermatologic symptoms, the NAMCS data indicate that most (72%) of these patients are also seen by a physician. Third, physicians are ultimately responsible for the actions of their PA employee. A general practitioner not trained to perform excisions or manage certain dermatologic conditions should not allow a PA to perform such duties. Similar to much of medicine, the PA profession continues to evolve, with many members moving awa

Delivery of Health Care↗
PubMed1998

Managed care: future good news or bad news for vascular surgeons.

Recently, William W. McGuire, Chief Executive Officer of United Health-Care, emphasized that the key from the patient's viewpoint is access. He stated, "We use the term gateway rather than gatekeeper." He emphasizes the importance of direct access of the patient to the right physician, whether it be a specialist or a generalist. Although some health care strategists believe that patients should initially see a generalist before receiving specialty care, this approach may not save dollars in the long run. Managed care is likely to have a major impact on vascular surgeons. Currently, business purchasing cooperatives are one model for containing costs of expensive invasive procedures among the working population. Such cooperatives are likely to achieve a stronger penetration in the health care market and to negotiate aggressively for packaged fee contracts for specialized cardiovascular care and procedures. Because the vast majority of vascular patients are more than 65 years of age, the movement of Medicare toward managed care may also affect vascular surgery in a major way. If vascular surgeons are to survive financially in the managed care environment, they must continue to provide evidence-based solutions to clinical problems at a reasonable cost and with good outcomes. They must also understand that involvement in the administrative and political leadership of health care is essential to maintaining some influence on the future reimbursement for our services.

Contract Services↗
PubMed2000

Managed care and the geriatric patient-physician relationship.

As managed care proliferates in the United States and other countries, its structure has patterned changes in patient-doctor relationships, including those between older patients and their physicians. The physician as gatekeeper now limits the access of the patient to information and services. Patient trust in the physician, essential to an effective patient-doctor relationship, will be damaged under this system of care. Additionally, examples from medical encounters demonstrate that many of the problems in the doctor-older patient relationship found under fee for service will remain, including the lack of attention to the contextual issues of health care of older adults.

Adult↗
PubMed2003

Medical assessment for health advocacy and practical strategies for exercise initiation.

The universal caution to consult your family doctor before beginning an exercise program creates an image of exercise as potentially harmful. Moreover, insistence on extensive screening prior to exercise is both unrealistic and often inappropriate for the older adult. Recasting the role of the physician as a physical activity advocate rather than as a gatekeeper is recommended for incorporation into guidelines for exercise screening. A geriatric assessment focusing on identification of specific parameters predictive of disablement risk can be incorporated into the exercise prescription as a guide for initiating exercise. The purpose of this article is to: (1). review the role of the primary care physician in screening and advocating exercise; (2). examine objectively the risk of exercise among older adults and place these risks in context with current screening guidelines with a particular emphasis on the exercise test; and (3). examine how key concepts derived from epidemiologic studies of disability can be distilled into practical guidelines for exercise therapy. We provide an overview of relevant literature related to screening and initiating exercise. Key challenges are highlighted and discussed. Suggestions for changes in policy are recommended. Given the apparent discordance between screening guidelines for the older adult and risk of adverse events, and between existing recommendations for physical activity and epidemiologic studies of disability, an evidence-based approach is recommended to review and revise screening and prescribing practices.

Aged↗
PubMed1996

Ten rules for reading clinical research reports.

This was not a scientific assessment of the scientific quality of the papers published by The American Journal of Surgery. It was an informal audit of the adequacy of the data analysis in the clinical research reports appearing in the 1987-1988 issues. As one who has devoted more than three decades to helping a great variety of people make sense of scientific data, I found the overall quality of data analysis in these papers to be above average for the medical literature; and yet, I found many instances of errors so serious as to render invalid the conclusions of the authors. My 10 proposed rules for reading clinical research reports constitute only an interim solution to a very worrisome problem. The real solution must come from the producers of and the gatekeepers for the medical literature.

Data Interpretation, Statistical↗