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PubMed1999

Assessing the performance of NHS hospital trusts: the role of 'hard' and 'soft' information.

Formal performance measurement systems have become a prominent feature throughout most of the public sector. The NHS is no exception and the government is developing and expanding on existing performance data to produce a new national framework which is to be at the heart of the 'performance-led' NHS. The success of formal performance measurement systems depends in part on the degree to which they can capture adequately relevant information within a quantitative framework. In this paper, we explore the use of formal, quantitative 'hard' information and informal, subjective 'soft' information in the assessment of the performance of NHS hospital Trusts by external organisations. Our empirical work is summarised into 3 main themes: (i) the use of 'soft' information as a complement to 'hard' information; (ii) the use of 'soft' information as a substitute for 'hard' information; and (iii) the use of 'hard' information as a safety net in the assessment of performance. We argue that 'soft' information plays a valuable role in the assessment of performance of NHS Trusts and note that this is also reflected in current practice in the private sector. We argue that one of the main functions of 'hard' information in performance assessment is to act as a safety net in order to identify laggards by highlighting poor performance. Rarely is it used as a means to encourage good performance or to identify best practice. Whilst the safety net function may indeed be useful, if the new national performance framework is to achieve its aim of promoting good performance, the limitations of formal systems will have to be taken into account. We argue that the advantages of 'soft' information in the NHS should be acknowledged, rather than trying to force it into a formal framework where the benefits may be nullified. However, we also warn against excessive reliance on 'soft' information and suggest that a balanced system which allows both 'hard' and 'soft' information to flourish is the optimal solution to performance assessment in the NHS.

Efficiency, Organizational↗
PubMedDate not supplied

[Estimating the coverage of systematic vaccinations among the Balearic Island infant population].

BACKGROUND: In order for vaccination programs to be carried out properly, it is essential for the vaccination coverage to be known. On the Balearic Islands, the reported coverage was much less than for the rest of Spain. The objective of this study is that of estimating the coverage of the vaccinations included on the recommended schedule up to 18 months of age (4 doses of oral polio, tetanus and diphtheria; 3 doses of whooping cough; 1 dose of measles, rubella and mumps). METHODS: A descriptive, cross-sectional study of the population base. The ideal-time frequency distribution estimators and the corresponding confidence intervals were calculated at 95% (CI95%) for a sample of the resident two-year-old (born in 1995) Balearic Island population selected by means of a single-stage conglomerate random sampling based on census sections. The National Public Health System and National Health Institute vaccination records were reviewed, the data from the vaccination document having been requested from the families and the clinical record from the private pediatricians by telephone. RESULTS: The sample included 606 children, it having been possible to obtain full information on 532 children. Full information was obtained on 377 cases (62%) from the public health sector records. The least degree of coverage was found for the diphtheria vaccine, 518 children having been fully vaccinated, 96.8% (CI95% = 94.8-98.1), the highest degree of coverage having been found for the whooping cough vaccine, 537 children, 98.9% (CI95% = 97.5-99.5). CONCLUSIONS: Good vaccination coverage was found to exist on the Balearic Islands, being similar to what has been being estimated for Spain as a whole. The objective included within the Polio Eradication Plan is accomplished, very little information being gathered from the public sector.

Catchment Area, Health↗
PubMed2004

Developing a national performance indicator framework for the Dutch health system.

OBJECTIVE: To report on the first phase of the development of a national performance indicator framework for the Dutch health system. METHODS: In January 2002, we initiated an informed interactive process with the intended users-policymakers at the Ministry of Health, Welfare and Sport-and academics to develop both the conceptual framework and its content. Decisions were based on consensus after discussing strategic goals of the health system, information needs of policy makers at the Ministry of Health, Welfare and Sport, and studying existing theory and international experiences with national performance indicator frameworks. We identified objectives and criteria for a framework at the national level, constructed a conceptual model, and selected indicator areas. RESULTS: As a starting point we chose a balanced scorecard reflecting four perspectives towards health system management information at the national level. These perspectives are consumer orientation, finances, delivery of high quality care, and the ability to learn and grow. We then linked the Lalonde model for population health to a balanced scorecard model. The constructed model makes the relationship between population health and health system management apparent, and facilitates the presentation of performance information from various perspectives. The model reflects the strategic goals of the Dutch health system, i.e. contributing to the production of health by providing necessary health care of good quality that is accessible for all Dutch citizens while simultaneously informing policy makers about the performance of the entire health system in all sectors (care, cure, prevention, and social services). The selected indicator areas for health system management information (20 in total) reflect the policy and management functions of the government and the defined public goals of the health system. The model was formally adopted by the Ministry of Health, Welfare and Sport in February 2003, and since then individual indicator areas have been operationalized by 30 representatives of various departments at the Ministry with continuous external research support. CONCLUSION: The merit of linking the balanced scorecard inspired model to public health data is that it facilitates the visualization of the contribution of the health system to the improvement of population health. The method of an intensive interactive indicator development process between policy makers and researchers has so far proven successful.

Delivery of Health Care↗
PubMed1999

Estimate of the global market for rifampicin-containing fixed-dose combination tablets.

SETTING: Despite WHO and IUATLD recommendations to use fixed-dose combination (FDC) tablets for treatment of tuberculosis, more than 75% of all rifampicin used in the public sector globally is administered as single drug tablets. OBJECTIVE: To estimate the potential global market for rifampicin-containing FDCs in the public and private sectors. DESIGN: The public sector market for FDCs was calculated from the number of tuberculosis cases notified to WHO for 1996 and from information on treatment regimens currently used in each country. The private sector market was calculated from the estimated number of treated tuberculosis cases and the treatment regimens presumed to be used in the private sector. RESULTS: The potential global market for the four-drug FDC tablet (rifampicin 150 mg, isoniazid 75 mg, pyrazinamide 400 mg and ethambutol 275 mg) is 305 (90%CI 145-505) million tablets per year, 105 (90%CI 50-160) and 200 (90%CI 95-345) million of which would be distributed in the public and private sectors, respectively. The uncertainty of the estimate remains considerable, as shown by the 90% confidence intervals. CONCLUSION: The study demonstrated a large potential global market for FDCs that should encourage pharmaceutical manufacturers to produce WHO-recommended dosages of FDCs at affordable prices.

Antibiotics, Antitubercular↗
PubMedDate not supplied

Obtaining greater value from health care: the roles of the U.S. government.

The problems of quality and cost in the U.S. health care system are unlikely to be solved without strong leadership from the federal government, which can mobilize action to set national priorities for quality; develop and promulgate standards for care; and stimulate implementation of performance measures and standards for providers. All of these functions would best be carried out by a new federal agency. Furthermore, the federal government should design payment policies based on the performance standards, invest in needed information technology, and invest in research related to improving care and in training professionals to support nationwide quality improvement.

Federal Government↗
PubMed2006

The Italian surveillance system for occupational cancers: characteristics, initial results, and future prospects.

BACKGROUND: Occupational cancer monitoring is important for cancer prevention and public health protection. A surveillance system for identifying occupational cancer risks and cancer cases in Italy that are likely to be of occupational origin using information available in the Italian Social Security archives was created and assessed. Persons employed in the private sector, the employing company, its industrial sector, and years of employment are available in these archives. METHODS: A method to find known occupational hazards was first tested using a case-control approach. Cases were from six Italian cancer registries (CRs) and controls were sampled from source populations and as "exposure" the economic sector of the employing company was used. The potential of using hospital discharge records as case sources was subsequently assessed: these cover larger populations and are available more quickly than CR case series. RESULTS: In the CR-based study many known occupational cancer risks related to specific industrial sectors were identified. By using cases from hospital discharge records many industries at risk were identified, as well as cases of recent diagnosis likely to be of occupational origin. However, for some industrial sectors (e.g., the chemical industry) the approach was unable to detect any excess risk. Furthermore, information on employees in important areas like agriculture, self-employment, and the public sector is not available in the Social Security archives. CONCLUSIONS: This approach appears to be a promising low-cost method for occupational cancer surveillance, at least for some industries, and can be easily implemented in other countries.

Adult↗
PubMedDate not supplied

National health accounts in developing countries: appropriate methods and recent applications.

Better information on the financing of the health sector is an essential basis for wise policy change in the area of health sector reform. Analysis of health care financing should begin with sound estimates of national health expenditure--total spending, the contributions to spending from different sources and the claims on spending by different uses of the funds. The member countries of the OECD have successfully established such comparative health expenditure accounts in terms of standardized definitions of the uses of funds and breakdowns by public and private sector sources. This has resulted in important research on health system differences which could explain variations in the level and composition of financing. The United States has developed a more detailed approach called National Health Accounts, which expands the OECD method into a more disaggregated 'sources and uses' matrix. In the developing countries, analysis of health expenditures has been much less systematic, despite several decades of calls by international researchers for more attention. This paper reviews previous work done in developing countries and proposes renewed attention to national health expenditures, adapting the recent experience of the United States. Because most developing countries have more pluralistic health financing structures than are found in most industrialized countries, an enhanced and adapted version of the 'sources and uses' matrix method is proposed. This method should be modified to address the relevant categories of expenditures prevalent in the developing countries. Examples of recent applications of such 'national health accounts' from the Philippines, Egypt, India, Mexico, Colombia and Zambia are presented. Experience to date suggests that development of sound estimates using this method in low and middle income countries is feasible and affordable. National health accounts estimates can significantly influence policy. They provide decision makers with a holistic picture of the health sector, showing the actual emphasis of spending and the roles of different payers. They also provide a consistent framework for modelling reforms and for monitoring the effects of changes in financing and provision. An easy to use software tool has been developed for training and data management. Regional networks of collaborating national groups are proposed as a first step in expanding use of the method and to gain both national and cross-national comparative benefits.

Accounting↗
PubMed1996

MRI of peripheral joints with a low-field dedicated system: a reliable and cost-effective alternative to high-field units?

In the age of health care cost containment new imaging technology has to meet diagnostic requirements as well as economic limitations. In the MR sector new dedicated systems promise reliable diagnostic information at considerably lower costs than whole-body imagers. Within the past 18 months we have examined 2200 patients with acute and chronic lesions of peripheral joints (knee, ankle, foot, elbow, wrist, hand) in a 0.2T dedicated MR system (ARTOSCAN, Esaote Biomedica, Genoa, Italy). We report our experience with this system focusing on its special features, cost-effectiveness and on diagnostic accuracy of low-field MR studies of the knee in correlation with arthroscopy and in comparison with high-field whole-body imagers.

Acute Disease↗
PubMed1996

A computer network with SCADA and case tools for on-line process control in greenhouses.

Climate control computers in greenhouses are used to control heating and ventilation, supply water and dilute and dispense nutrients. They integrate models into optimally controlled systems. This paper describes how information technology, as in use in other sectors of industry, is applied to greenhouse control. The introduction of modern software and hardware concepts in horticulture adds power and extra oppurtunities to climate contol in greenhouses.

Agriculture↗
PubMed1988

Revision of the Italian psychiatric reform: north/south differences and future strategies.

The Italian psychiatric reform of 1978 shifted the care of the mentally ill from the asylum to the community, by prohibiting new admissions to asylums and providing new community-oriented services. Ten years later, the Italian government is reviewing the effects of the psychiatric reform and is considering drastic revisions of the Law. However, few data are available to evaluate the impact of the new legislation on a national basis. The present cross-sectional study, conducted in North-Central and Southern Italy, showed that a more socially disadvantaged patient population was treated in Southern Italian mental health services. In both geographic regions, the probability of being currently treated in mental hospitals as compared to community services was increased by poor education, being unmarried, having a schizophrenia or organic diagnosis, a long psychiatric history, a long previous hospitalization, or a poor prognosis. However, a long psychiatric history was the main factor associated with current mental hospital treatment in Southern Italy but not in the North-Center, thus suggesting that the psychiatric reform has had different impacts on Northern and Southern mental hospitals. The inadequate provision of community-oriented services in Southern Italy regions, and the presence of private mental hospitals that are publicly reimbursed, contribute importantly to the unsatisfactory situation of mental health care delivery in Southern Italy. The reinstitutionalization of mental patients is currently proposed by some political parties in Italy. This article argues that new legislation must address the provision of effective community services in the South, better definition of the role of the private sector, and the creation of an effective information system to monitor the implementation of the proposed measures.

Community Mental Health Services↗
PubMed2004

The pallidofugal motor fiber system in primates.

The organization of the pallidofugal fiber system originating from the internal segment of the globus pallidus (GPi) in cynomolgus monkeys (Macaca fascicularis) was studied by means of a single-axon tracing method. The primate GPi is composed of a majority of neurons endowed with a highly collateralized axon that projects to the premotor neurons located in the ventral tier thalamic nuclei, the center-médian/parafascicular thalamic complex and the brainstem pedunculopontine nucleus. These axons often follow a long and tortuous course within the GPi and then emerge either through the ansa lenticularis (AL) or the lenticular fasciculus (LF), irrespective of the location of their parent cell body in the GPi. Other pallidofugal axons exit through the medial pole of the GPi, at various distances between the AL ventrally and the LF dorsally. Virtually all pallidofugal axons course through Forel's field H, on their way to the thalamus and brainstem. They emit numerous short collaterals and boutons en passant in this sector of the subthalamic region, which stands out as a major target of GPi axons. Our results indicate that AL and LF do not form separate anatomical entities, each carrying axons originating from distinct functional pallidal territories, as commonly believed. Instead, these two fascicles form the ventral and dorsal borders of a morphological continuum that harbors a multitude of pallidofugal axons arising from all sectors of the GPi. This type of information should be taken into account when interpreting data from deep brain stimulation applied to pallidal and subthalamic regions in Parkinson's disease.

Animals↗
PubMed2000

Measuring the prevalence of sector-specific problem gambling: a study of casino patrons.

This study is the first attempt to measure the prevalence of problem gambling attributable to a specific sector of the gambling industry. One thousand, one hundred and five casino patrons in 40 casinos in the UK were interviewed, face-to-face. Respondents were screened for problem gambling using a multiple response version of DSM-IV (DSM-IV-MR). The study found support for Eadington's (1988) hypothesis, that UK casinos could be largely sustained by regular players, among whom the prevalence of problem gambling is high. The study also found support for the hypothesis that, to the extent different gambling sectors are patronised by demographically different client groups, so the problem gamblers associated with them will reflect these client groups. The problem gamblers among the regular casino patrons were demographically distinct from the problem gamblers in the sample who showed a preference for other gambling forms. Other key findings support those found in other jurisdictions. Sector-specific prevalence studies may be the next step forward in epidemiological research on problem gambling. They have the major advantage of netting significantly more problem gamblers from much smaller samples than similar studies in the general population. They also have the potential to reveal the proportion of problem gamblers attributable to each sector, along with their demographic characteristics. Such information would result in more specific information being available for regulators seeking to minimise the social impact of problem gambling and those involved in the development of prevention and treatment strategies.

Journal Article↗
PubMed1998

Self-reported need of information, counselling and education: needs and interests of re-applicants.

An interview study was performed to establish and evaluate the need for education and counselling of hearing aid users (HA users) in order to review present procedures of information and potential referral to the educational sector. The study comprises 102 consecutively selected hearing-impaired adults (>18 years), the only inclusion criterion being experienced HA user. The interview took place immediately after the patient's latest HA fitting appointment and consisted of 24 structured and closed questions. The findings indicate that a significant proportion of HA users, especially the elderly, do not experience a need for or show an interest in further education and counselling concerning their hearing handicap. It is concluded that the present organization of services meets the demands of a majority of re-applicants.

Adult↗
PubMed2001

The future is noisy: the role of spatial fluctuations in genetic switching.

A genetic switch may be realized by a certain operator sector on the DNA strand from which either genetic code, to the left or to the right of this operator sector, can be transcribed and the corresponding information processed. This switch is controlled by messenger molecules, i.e., they determine to which side the switch is flipped. Recently, it has been realized that noise plays an elementary role in genetic switching, and the effect of number fluctuations of the messenger molecules have been explored. Here we argue that the assumption of well stirredness taken in the previous models may not be sufficient to characterize the influence of noise: spatial fluctuations play a non-negligible part in cellular genetic switching processes.

Bacteriophage T4↗
PubMed1999

Identifying and mapping community vulnerability.

Disaster vulnerability is socially constructed, i.e., it arises out of the social and economic circumstances of everyday living. Most often discussed from the perspective of developing nations, this article extends the argument using American demographic trends. Examples from recent disasters, Hurricane Andrew in particular, illustrate how certain categories of people, such as the poor, the elderly, women-headed households and recent residents, are at greater risk throughout the disaster response process. Knowledge of where these groups are concentrated within communities and the general nature of their circumstances is an important step towards effective emergency management. Emergency planners, policy-makers and responding organisations are encouraged to identify and locate high-risk sectors on Community Vulnerability Maps, integrating this information into GIS systems where feasible. Effective disaster management calls for aggressively involving these neighbourhoods and groups at all levels of planning and response, as well as mitigation efforts that address the root causes of vulnerability.

Aged↗
PubMedDate not supplied

No Toyotas in health care: why medical care has not evolved to meet patients' needs.

The incentives and structure of health care in the United States produce exactly what we should expect in the quality of care for chronic disease: highly variable patterns of care and widespread failure to implement evidence-based best practices. The persistent inability of providers to improve patterns of practice is due in part to the lack of a "business case for quality." Providers cannot anticipate that quality improvements will result in higher prices, increased volume, or decreased costs. However, signs of a business case for quality are emerging, fueled by cost pressures, the increased availability of data, informed consumers, and public- and private-sector purchaser initiatives.

Chronic Disease↗
PubMedDate not supplied

[Comparative analysis of Andean and Caribbean region health systems].

OBJECTIVE: Carrying out a comparative analysis of Andean and Caribbean health systems contributing towards the general panorama of Andean and Caribbean region health care system experience. METHODS: This study was aimed at carrying out a comparative analysis of health systems in Bolivia, Colombia, Ecuador, Peru, Venezuela, the Dominican Republic and Cuba between 1990 and 2004. Documentary information from secondary sources was used. Reform and changes during the aforementioned period were compared, as well as the systems' current configurations. Described typologies were used for studying the health systems. RESULTS: Different organisational designs were found for the systems: a national health system (NHS), segmented systems and systems based on mandatory insurance. The trend of reforms introduced in the 1990s and current proposals in almost all systems are directed towards adopting mandatory insurance via a basic packet of services and strengthening competition in providing services through a public and private mix. CONCLUSIONS: The organisation and structure of most systems studied have introduced and continue to introduce changes in line with international guidelines. The generality of these structures means that efforts must still be made to adopt designs strengthening them as instruments improving populations' quality of life. Comparative analysis is a tool leading to studying health systems and producing information which can nourish debate regarding current sector reform. This work took shape during the first approach to a comparative study of Andean region and Caribbean health systems.

Bolivia↗