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California↗
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Understanding venous leg ulcer pain: results of a longitudinal study.
Venous leg ulcer pain experienced during compression bandaging is poorly understood. A prospective, pilot cohort study was initiated to determine the feasibility of conducting a large-scale, repeated measures cohort study of venous leg ulcer pain and to document and describe the venous leg ulcer pain experience during the first 5 weeks of treatment with compression bandages. Eligible individuals admitted to a nurse-led community leg ulcer service in one Canadian community were recruited for the 5-week study. Pain assessment tools (ie, numerical rating scale and short form McGill Pain Questionnaire) were evaluated by 20 venous ulcer patients (mean age = 73.7 years) and their nurses for ease of use during one baseline and five weekly follow-up visits. Health-related quality of life (HRQL) information was obtained. Nurses reported on ease of integrating pain data collection into regular clinical care. Each pain assessment tool was audited for completion. Most participants found the pain assessment tools easy to use, but nurses reported lengthened visit times with some participants as a result of tool administration difficulties, particularly the visual analogue scale (VAS). Overall completeness of pain assessment tools ranged from 85.0% (visual analogue scale) to 96.3% (present pain intensity and word descriptor list). The vast majority of patients (18) reported ulcer pain at baseline. Total mean scores for all pain assessment tools used decreased over time, but most patients reported pain throughout the study. The most common pain descriptors used were "aching," "stabbing," "sharp," "tender," and "tiring." Health-related quality of life was low and did not change during the 5-week study. The results of this study suggest that the vast majority of venous ulcer patients experience pain and that it is feasible to examine this pain in individuals receiving care in the community over time.
Activities of Daily Living↗
Understanding cultural significance, the edible mushrooms case.
BACKGROUND: Cultural significance is a keystone in quantitative ethnobiology, which offers the possibility to make inferences about traditional nomenclature systems, use, appropriation and valuing of natural resources. In the present work, using as model the traditional mycological knowledge of Zapotecs from Oaxaca, Mexico, we analyze the cultural significance of wild edible resources. METHODS: In 2003 we applied 95 questionnaires to a random sample of informants. With this data we integrated the Edible Mushroom Cultural Significance Index. This index included eight variables: frequency of mention, perceived abundance, use frequency, taste, multifunctional food use, knowledge transmission, health and economy. Data were analyzed in an inductive perspective using ordination and grouping techniques to reveal the behavior of species in a cultural multivariate dimension. RESULTS: In each variable the species had different conducts. Cantharellus cibarius s.l. was the species with most frequency of mention. Pleurotus sp. had the highest perceived abundance. C. cibarius s.l. was the most frequently consumed species. Gomphus clavatus was the most palatable species and also ranked highest in the multifunctional food index. Cortinarius secc. Malacii sp. had the highest traditional importance. Only Tricholoma magnivelare was identified as a health enhancer. It also had the most economic importance. According to the compound index, C. cibarius s.l., the Amanita caesarea complex, Ramaria spp. and Neolentinus lepideus were the mushrooms with highest cultural significance. Multivariate analysis showed that interviewees identify three main groups of mushrooms: species with high traditional values, frequent consumption and known by the majority; species that are less known, infrequently consumed and without salient characteristics; and species with low traditional values, with high economic value and health enhancers. CONCLUSION: The compound index divided the cultural significance into several cultural domains and showed the causes that underlie this phenomenon. This approach can be used in cross-cultural studies because it brings a list with the relative position of species among a cultural significance gradient. This list is suitable for comparisons and also it is flexible because cultural variables can be included or removed to adjust it to the nature of the different cultures or resources under study.
Adult↗
A 'chronic disorder' health-care model for children with complex developmental disorders.
OBJECTIVES: To conceptualize, develop and evaluate a 'chronic disorder' clinical model of health services for children with 'low-severity' developmental disorders assessed and treated within a public Child Development Unit. METHODOLOGY: Concepts of family empowerment, child resiliency and the management of clinical complexity were explicitly incorporated into the service model and the clinical strategies in order to address long-term goals of prevention and health promotion. To explore the efficacy of this model, a telephone audit survey was conducted of parents of 42 children seen sequentially through this modified service. RESULTS: Parent data indicate a high level of satisfaction with the integrated, individualized assessment processes and effective transmission of information through both written reports and dedicated discussion visits. A treatment methodology based on parent chosen treatment goals for short and long time-frames was experienced as achievable and successful. CONCLUSIONS: These data suggest that the service goals of an integrated team process, parent empowerment and effective clinical collaborations may be achievable from a health care setting. A change in emphasis from remedial treatment to adaptation, health promotion and tertiary prevention is integral to these strategies. The concepts, clinical model and evaluation are presented to stimulate discussion around the question of what child health services are attempting to achieve for children with complex developmental disorders.
Australia↗
[Twenty years of care for persons living with HIV/AIDS in Brazil: the health professionals' perspective].
The aim of this study was to describe the meaning ascribed by health professionals to the care they provide for persons with HIV/AIDS. Data were collected through recorded interviews with 10 health professionals providing care to AIDS patients in different institutions in São Paulo State, Brazil. Three themes emerged from the analysis: (a) the overall scenario of healthcare provision for AIDS patients; (b) the relationship between healthcare professionals and patients; and (c) ethical aspects related to care. Despite significant advances, the study identified discriminatory behavior in the treatment. Such behaviors were related to feelings of insecurity and fear of infection on the part of healthcare professionals, which could be explained by the lack of appropriate training in general services and hospitals. Specific training for treating the patients mainly targeted health professionals in centers specializing in HIV/AIDS, resulting in difficulties for integrating the care of these patients with other services under the Unified National Health System. The data related to characteristics of professional training in the health field as a whole, leading one to reflect on the skills expected of health professionals in caring for (and relating to) persons with HIV/AIDS, as well as the impact on AIDS prevention.
Acquired Immunodeficiency Syndrome↗
Employer initiatives to examine cost and quality in health care.
Actions by private sector employers as well as moves by federal and state agencies have begun the process of integrating cost and quality in health care decision making.
Data Collection↗
Cerner Millennium: the Innsbruck experience.
OBJECTIVES: A Clinical Information System, serving more than 2,000 users was to be implemented at three hospitals of TILAK (Tiroler Landeskrankenanstalten GmbH), including the University Hospital of Innsbruck. The system was intended to integrate data from radiology, laboratory, and pathology subsystems with patient data. METHODS: Using Cerner Millennium software and Health Level 7 standards, the first stage of an Electronic Patient Record (EPR) was built. Direct data entry was facilitated using either a Microsoft Word text processor (with subsequent authentication workflow) or structured forms. An enterprise-wide scheduling module allows coordination and storage of patient appointments directly in the EPR. As required by security policy, the Cerner software regulates the varying degrees of information exchange among organizations and departments within the enterprise. RESULTS: First experiences indicate satisfactory acceptance of system functionalities. The introduction of Cerner Millennium at TILAK has achieved essential goals defined at the beginning of the project. Basic functionalities--free text documentation, standardized documentation, scheduling, and some parts of order entry--are offered in a user friendly manner. Integration with existing systems to complete the EPR has been successful using standard interfaces (HL7). CONCLUSION: TILAK concluded that it was possible to successfully implement a Clinical Information System (CIS) developed mainly for the American market in a European healthcare environment. Some adaptations and functional extensions were necessary (e.g., the discharge summary "Arztbrief"). The system had enough flexibility to meet the requirements and specifications of European healthcare processes. A key factor of success was the establishment of a basic level of understanding and communication between the software vendor and the TILAK user community.
Austria↗
The costs of caring for stroke patients in a GP-led community hospital: an application of programme budgeting and marginal analysis.
There has been little evaluation of the role of community hospitals in the provision of integrated health care services in a primary care-led health system. The aim of this study was to model the probable changes in the use of NHS resources from the introduction of integrated stroke care in a general pracititioner-led community hospital. A programme budgeting and marginal analysis (PBMA) exercise was conducted combining practice data for the 'before' period and data from the literature to model the 'after' period. Data were collected from all patients discharged with a primary diagnosis of stroke 1994-96 in Nairn and Ardersier Total Fundholding pilot site, Highland Health Board, Scotland. Under several assumptions, a policy of early discharge of patients to the community hospital, and/or avoiding admission at the acute trust and admitting patients to the community hospital directly (except emergencies), is likely to result in a reduction of the total annual costs of treating stroke patients, from 183,000 pounds per annum to, at most, 74,000 pounds. The analysis of routine discharge data since integrated stroke care was set up has shown that progress has been made in shifting the treatment of patients from the acute trust to the community hospital. The care of stroke patients in a GP-led community hospital is likely to reduce the use of scarce health service resources. Current evidence suggests that health outcomes are unchanged due to early discharge, but further research is required to ensure that patients' health status and quality of life are maintained before such a policy is widely adopted.
Adult↗
Competitive forces in the medical group industry: a stakeholder perspective.
Applying Porter's model of competitive forces to health care, stakeholder concepts are integrated to analyze the future of medical groups. Using both quantitative survey and qualitative observational data, competitors, physician suppliers, integrated systems new entrants, patient and managed care buyers, and hospitals substitutes are examined.
Cooperative Behavior↗
Health care informatics.
The health care industry is currently experiencing a fundamental change. Health care organizations are reorganizing their processes to reduce costs, be more competitive, and provide better and more personalized customer care. This new business strategy requires health care organizations to implement new technologies, such as Internet applications, enterprise systems, and mobile technologies in order to achieve their desired business changes. This article offers a conceptual model for implementing new information systems, integrating internal data, and linking suppliers and patients.
Computer Communication Networks↗
A health outcomes framework for assessing health status and quality of life: enhanced data for decision making.
BACKGROUND: Currently, information to improve health status and quality of life is derived from independently designed data systems that range from population-based health surveys to health records used in managing individual patient care. But there is no coherent strategy for using these data sources in concert across diverse applications. Thus, it is frequently difficult to compare or combine results across studies to provide population-level inferences based on findings from specific subpopulations. OBJECTIVE: The Health Outcomes Framework is an analytic structure to provide more comprehensive information about the health status and quality-of-life impact of disease and its treatment. This framework consists of three components: (1) a core set of health, lifestyle, and economic questionnaires that collect data from an individual's perspective; (2) applications that range from population to patient care levels; and (3) time. Although health is the outcome of interest, lifestyle behaviors and economic and political factors are important determinants of health, which also need to be studied using standardized procedures; thus, they are included in the core. This article focuses on the nature and application of a core health status and quality-of-life instrument. To be useful across a range of applications, such a core instrument needs to have three conceptual characteristics: (1) a theoretical model that regards health as a continuum of states; (2) domains that represent policy-relevant aspects of impairment, disability, and handicap; and (3) a set of societal preferences for these domains. In addition, the core needs to address three practical concerns: (1) brevity, (2) methods of administration that are suitable for respondents with diverse capabilities, and (3) documentation that is publicly available. These features are discussed using examples from currently available, multi-domain generic instruments, each of which has some, but not all, of the necessary features of the core instrument. CONCLUSION: The Health Outcomes Framework is intended to be a cooperative effort. It is proposed that the National Cancer Institute and the Centers for Disease Control and Prevention take leadership roles not only by adopting a core health status and quality-of-life instrument for use in current and future cancer data collection activities but also in encouraging industry and academic investigators to implement this core instrument in their cancer studies. Having a vertically integrated core instrument can lead to more representative data for informing decision making and ultimately for obtaining a more equitable distribution of health.
Decision Making↗
Developing a research strategy for acupuncture.
This strategic overview revisits some of the basic assumptions that relate to the clinical evaluation of acupuncture. We look at the evidence available to estimate both the specific and nonspecific effect size of acupuncture (efficacy and effectiveness) and consider the placebo within acupuncture trials, as well as the value of both placebo controlled trials and pragmatic acupuncture studies. We argue for an augmented, mixed methodology that integrates basic mechanism studies, including modern imaging techniques such as functional magnetic resonance, quantitative and qualitative research, as well as safety and health economic data to obtain a more rigorous understanding of acupuncture. We hope that by taking a broad, patient-centered, and rigorous approach we may arrive at a realistic and thoughtful evaluation of its relative value in comparison to placebo treatment, conventional medicine, and its potential for integration into conventional clinical care.
Acupuncture↗
From Kilimanjaro to the Himalayas: studies of health determinants in Third World communities.
Studies in communities in developing countries may seem far from occupational medicine in the UK, but there is much in common. Poverty and inequality, and the lack of control and choices that follow, are important causes of ill health. The methodology described in this paper is based on the concept that measurement should itself contribute to development and empower people. It combines quantitative data from large scale household surveys with qualitative data from focus groups, key informants and institutional reviews. In Nepal, malnutrition in children is seen to be related not only to feeding practices but also to the status of women. In Uganda, highlighting areas of poor service delivery in health and agriculture has initiated dialogue about improving local delivery of these services. In Tanzania, corruption in public services adversely affects everyday life; the survey results are part of an integrated strategy to tackle the problem.
Community Health Services↗
Developing a culture of safety in the Veterans Health Administration.
CONTEXT: Weaving patient safety into the fabric of clinical activities is an increasingly important aspect of medical care. OBJECTIVE: To detail the steps taken by the Veterans Health Administration (VHA) to integrate patient safety into its organizational structure. DESIGN: Descriptive study. SETTING: VHA. DATA SOURCES: VHA documents, congressional testimony, the medical literature, the general press, and personal communications. RESULTS: The VHA leadership has taken steps to promote a culture of safety by making public commitments to improving patient safety, allocating resources toward establishment of special centers, enhancing employee education on patient safety, and providing incentives to promote safety. The VHA is also establishing one mandatory and one voluntary adverse event reporting system; in the latter case, the reporter remains anonymous. Examples of nationally mandated initiatives are bar coding of all medications and use of computerized medical record that includes order entry, laboratory and imaging results, and all encounter notes. CONCLUSIONS: The VHA's initial efforts may serve as a template for other health care organizations that wish to engineer a culture of safety. Although progress has been made, patient safety efforts require constant attention to guard against becoming a new bureaucracy or simply window dressing.
Hospitals, Veterans↗
Risk perception during information system development in non-profit health care organizations.
The perception of risk exposure among design team members during the early phases of information system development projects can provide valuable strategic information for clinical organizations. To develop a typology of perceived risks during information system development projects in health care, interviews were performed with key team members from a specialist clinic, primary health care, and an informatics research group, during the requirements specification. Phenomenological data analysis and secondary integration of the results in available theories were performed. System objectives, the user requirements definition procedure, the communication pattern between design team members and project management were found to be perceived as the main risk areas. In the secondary analysis, the technical factors, identified as preventing a maximization of the use of the resources, were lack of informatics knowledge among economic decision makers and differences between customers and suppliers regarding their views on the nature of system design. During the implementation of a given strategy, decision makers may consider the requests of their own sponsors in the first place and maximize the use of the project resources in the second place. Informatics knowledge plays a key role in risk perception during the development of an information system in health care. Political considerations by team members are important to take into regard, since these may influence technical and economic decisions.
Humans↗
Design and implementation of a smart card based healthcare information system.
Smart cards are used in information technologies as portable integrated devices with data storage and data processing capabilities. As in other fields, smart card use in health systems became popular due to their increased capacity and performance. Their efficient use with easy and fast data access facilities leads to implementation particularly widespread in security systems. In this paper, a smart card based healthcare information system is developed. The system uses smart card for personal identification and transfer of health data and provides data communication via a distributed protocol which is particularly developed for this study. Two smart card software modules are implemented that run on patient and healthcare professional smart cards, respectively. In addition to personal information, general health information about the patient is also loaded to patient smart card. Health care providers use their own smart cards to be authenticated on the system and to access data on patient cards. Encryption keys and digital signature keys stored on smart cards of the system are used for secure and authenticated data communication between clients and database servers over distributed object protocol. System is developed on Java platform by using object oriented architecture and design patterns.
Computer Communication Networks↗
Reducing disparity in behavioral health services: a report from the American College of Mental Health Administration.
UNLABELLED: The 2003 AMCHA Summit was an initial step. It served to provide a broad outline of the socio-political context and key issues involved in reducing disparities, and it provided some momentum for change. However, much more work remains to be done. The summit clearly demonstrated that the reduction of disparities requires a multi-level approach and multi-disciplinary leaders. As a neutral convener, AMCHA is in a unique position to help advance the debate and lead the field. The membership includes researchers, administrators, clinicians, and policy makers from all levels of the behavioral health system. As noted, a change agenda needs to include efforts at national, state, and local levels involving consumers, providers, purchasers, oversight organizations, and researchers. ACMHA is committed to advancing the field and helping the national effort to reduce disparities. Examples of potential projects include the following: Training: Much has been done to develop effective cultural-competency training modules and to guide states in its implementation. No one should reinvent the wheel at this time. Funding should be targeted to provide incentives to states for dissemination of existing training curricula and the documentation of effectiveness to all providers and administrators. DATA: Nationally, the field will benefit from data standards for the collection of and reporting on system disparities. This will facilitate interstate comparisons and provide baseline data for change efforts. Conducting surveys of providers, health plans, and public behavioral health systems on the availability and current uses of data by race and ethnicity is one example of a useful first step in this process of setting data standards. RESEARCH: Further research on the nature and causes of disparity is needed. There should be systematic research on factors influencing access, treatment, and outcomes for people of different cultures. Initially, because of the difficulties in deciding on standardized outcome measures, the encounter and claims data will provide the most useful information for analysis. Later, as standardized outcome measures are more widely utilized and the data collected, it may be possible to look for racial and ethnic differences in outcomes. The research agenda needs to be developed with a focus on services and health systems research data. Demonstrations: Demonstration efforts are urgently needed, similar to Connecticut's initiative, that integrate data on disparities with provider reporting, performance contracting, and system-wide interventions. These best practices need to be shared with the field. Coordination: The Summit showed that many are eager to learn from others in this area. As we move from further research to demonstration initiatives, AMCHA can play a role in coordinating these projects, particularly at the state and perhaps local levels. State efforts can benefit from best-practice presentations from other states and by an improved understanding of the nature and scope of the change required at a programmatic and local level. Local efforts need to clearly incorporate the views and perspectives of members of the community and consumers. The 2003 ACMHA Summit provided a foundation and a framework for work to proceed at all levels of the behavioral health delivery system. To accomplish meaningful change, we challenge SAMHSA, and the other federal agencies to provide the leadership to (1) develop common and core-performance measures focused on the reduction of disparities, (2) coordinate the research agenda, and (3) facilitate the use of new information technologies to collect and review these data. This is completely consistent with the vision of federal "leadership by example" that has been outlined by the Institute of Medicine (2003b) for the implementation of the "Crossing the Quality Chasm" report. We need to facilitate the efforts of the states and the federal government to identify and reduce disparities and provide a forum for states to share the results of their efforts, to benchmark their performance, and seek technical assistance. Over the next several years, we also expect that states will expand their efforts to implement evidence-based practices. However, we urge these states to implement existing evidence-based practices cautiously, especially with culturally diverse populations, due to the limited representation of ethnically diverse subjects in the research evidence on current practices. We strongly recommend collecting data on practice-based evidence-where effective interventions are routinely identified from existing practice and shared with the field, particularly those practices that seem effective with minority populations.
California↗
Measures of functional status and quality of life in chronic obstructive pulmonary disease.
A variety of studies exist as to methods of assessing quality of life in chronic obstructive pulmonary disease. Neither the American Thoracic Society nor the European Consensus Statement for COPD recommend any specific quality-of-life or functional assessment measure as a gold standard. The present study identifies measures of COPD quality of life and functional status reported in selected literature in 1994-1997. A total of 37 measures were identified; of these eight were measures of general health, 10 were COPD/disease-specific questionnaires, and 19 were functional status indices. These measures provide valuable data, and further study is necessary to determine which measures should be integrated into standards of care.
Attitude to Health↗