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A study in the Solomon Islands has revealed that training before the age of 20 and irregularity of remuneration are the main factors explaining why village health workers leave their posts. Other causes are dissatisfaction with levels of payment and promotion, lack of community support, and family concerns.
The costs of different transplantation procedures are analysed. The costs which are not covered by the regular hospital allowance are presented using kidney transplantation as an example. It can be demonstrated that the main costs of transplantation arise from post-operative medication. At the moment these costs are not completely covered by the special remunerations for kidney transplantation. Nevertheless kidney transplantation is the most cost-saving of all kidney replacement therapy procedures: during a three-year-treatment period a successful kidney transplantation will save 53% of costs in comparison to home dialysis, 49% compared to CAPD and 61% in the case of Limited-Care-dialysis.
OBJECTIVE: To determine the level of physician involvement in prehospital emergency medical services (EMS) in Canada, as compared with published principles of medical control and direction. DESIGN: Mail and telephone survey by means of a questionnaire from March to November 1991. SETTING: All Canadian provinces and territories. PARTICIPANTS: Fifty-six key prehospital EMS physicians, senior government administrators and senior representatives of the agencies responsible for licensing physicians in each province or territory. MAIN OUTCOME MEASURES: Responses to questions regarding the legislation, organization, administration, practice and regulation of medical direction and control by physicians in each province or territory. RESULTS: EMS legislation describing medical direction and control was completely lacking in five provinces and both territories and was incomplete in the remainder. Provincial guidelines written by physicians for prehospital patient care were present in only four provinces. Formal organization of medical directors varied from none to partially remunerated networks. Regional medical-director systems were present in three provinces, and local medical directors were required for all communities in three. Most rural ambulance services were found to engage physicians only when there was local interest. CONCLUSIONS: The level of physician involvement in the medical direction and control of EMS appears to be inconsistent across Canada and insufficient in most jurisdictions, as compared with accepted principles.
This occupational physiology study was undertaken within a wider applied-research framework designed to evaluate the occupational environment and its impact on workers at "Asarel" Mining and Milling Works. Analysis of activities showed physical effort (dynamic and static) to be the major problem at the open pit, though varying in extent between jobs (most prominent for blasters and bulldozerists). Nervous/emotional strain, while not leading, was sustained mostly by diggers and blasters, followed by drivers. Organization of work (shift regimen, no regulated breaks, stepwise schedule of days off work) was hardly appropriate and did not allow for recovery. Interviewed workers qualified working conditions as extremely unfavorable; they disapproved with the physical factors of the occupational environment, the workplace, the state of machines and devices, and remuneration for work performed. Exertion from work, assessed by pulse rate and energy expended, was moderate for most activities of diggers, drivers, and drillers. The burden of physical effort was great for blasters at the open pit and for diggers and drillers performing extra repair operations (pulse rate, 100-110 strokes/min; energy expended, 5.2-5.5 Kcal/min). Hardest and least attractive was the work of blasters at stores for explosive materials (pulse rate, 120-141 strokes/min; energy expended, 5.5-6.5 Kcal/min). These adverse factors of labor activities might produce a negative impact on worker health and performance, leading to occupational impairment of their musculoskeletal system, to labor-related disorders of their cardiovascular and nervous systems, etc. Preventive measures are thus necessary to limit physical exertion, optimize the work-and-rest regimen; also, there is a need for conducting pertinent preventive medical examinations, providing social measures (conditions for transportation, rest, nutrition, sports), etc.
1) Sri Lanka has achieved a high human development status; 2) The health sector, and particularly the government health sector, has played an important role in this achievement. 3) The health transition is going to increase the burden of disease and the demand for health services; 4) The government health services have been underfunded and the provincial health services have been more underfunded; 5) The most cost efficient health services, anywhere in the world, are government funded; 6) Therefore, it is our duty to lobby government to increase government funding for health services; 7) The preventive health service should continue to be funded fully by government. Prevention of non-communicable diseases should come within this orbit. Staff in preventive health services should be better remunerated; 8) The essential clinical package in the periphery must be improved to reduce by-passing and underutilization; 9) Management of tertiary health care facilities have to be strengthened. They should be given responsibility and autonomy; 10) A powerful unit should be established in the Ministry to study and implement cost recovery and cost containment in tertiary care institutions; 11) Senior doctors should take an active part in the management of the tertiary care institutions to make them more efficient. 12) Private hospitals should be supervised by the Ministry in order to ensure quality of care and to contain national health care costs:
OBJECTIVE: To determine whether location of postgraduate medical training and other factors are associated with the emigration of physicians from Canada to the United States. DESIGN: Case-control study, physicians were surveyed with the use of a questionnaire mailed in May 1994 (with a reminder sent in September 1994), responses to which were accepted until Dec. 31, 1994. PARTICIPANTS: Physicians randomly selected from the CMA database, 4000 with addresses in Canada and 4000 with current addresses in the United States and previous addresses in Canada. OUTCOME MEASURES: Sex, age, location of undergraduate and postgraduate medical training, qualifications, practice location, opinions concerning residence decisions, current satisfaction and plans. RESULTS: The overall response rate was 49.6% (50.0% among physicians in the United States and 49.2% among those in Canada). Age and sex distributions were similar among the 8000 questionnaire recipients and the nearly 4000 respondents. Physicians living in the United States were more likely to be older (mean 53.2 v. 49.6 years of age), male (87% v. 75%) and specialists (79% v. 52%) than those practising in Canada. Postgraduate training in the United States was associated with subsequent emigration (odds ratio 9.2, 95% confidence interval 7.8 to 10.7). However, in rating the importance of nine factors in the decision to emigrate or remain in Canada, there was no significant difference between the two groups in the rating assigned to location of postgraduate training. Professional factors rated most important by most physicians in both groups were professional/clinical autonomy, availability of medical facilities and job availability. Remuneration was considered an equally important factor by those in Canada and in the United States. Six of seven personal/family factors were rated as more important to their choice of practice location by respondents in Canada than by those in the United States. Current satisfaction was significantly higher among respondents in the United States. Most physicians in each group planned to continue practising at their current location. Of Canadian respondents, 22% indicated that they were more likely to move to the United States than they were a year beforehand, whereas 4% of US respondents indicated that they were more likely to return to Canada. CONCLUSIONS: Factors affecting the decision to move to the United States or remain in Canada can be categorized as "push" factors (e.g., government involvement) and "pull" factors (e.g., better geographic climate in the US). Factors can also be categorized by whether they are amenable to change (e.g., availability of medical facilities) or cannot be managed (e.g., proximity of relatives). An understanding of the reasons why physicians immigrate to the United States or remain in Canada is essential to planning physician resources nationally.
This study compares the effects of the salary payment in the former GDR with the fee for service remuneration in Germany for outpatient service. The investigation focused on home visits 3 by family doctors in Magdeburg in the first two quarters of the years 1985 and 1992. The retrospective study based on existing documentations. Main questions were the modification of frequency resp. nature and matter of home visits. The frequency of home visits increased by about 134%. Distributed by age-groups, the home visits at patients up to the age of 55 showed only a small increase. However, the increase with patients between 60 and 79 years of age was 350%. In particular, diseases of the ICD Group VII (diseases of the vascular system) were affected by the increase. In contrast to this home visits of nurses were influenced to a lesser degree by the system changes. These are indications that the increase in the home visits is not due to an increased demand for them.
OBJECTIVE: To explore physicians' responses to the needs for education in geriatrics identified by a community needs survey. DESIGN: Interviews conducted during a cross-sectional survey. SETTING: Private family practices in Calgary. PARTICIPANTS: Randomly selected family physicians in Calgary who had previously recruited patients for a community needs survey. Thirty of 60 volunteer physicians randomly selected for phase 1 of the study were interviewed. One physician recruited patients for phase 1 but declined to be interviewed. MAIN OUTCOME MEASURES: Demographic variables, practice characteristics, and opinions on urgency of potential topics for continuing medical education. RESULTS: Physicians agreed with community informants that they need more education about medication for the elderly, medical management, and mental health issues. Physicians did not perceive pressing needs for education in communication skills with patients, in compassion, or in health promotion for patients. Physicians identified many barriers to meeting needs identified by the community. Among the most notable obstacles were inadequate time, inadequate remuneration, and lack of accessible community resources. CONCLUSIONS: Continuing medical education should help physicians recognize the community's needs and design programs that will address them.
OBJECTIVE: To obtain information about new-to-practice family physicians' attitudes toward current health policy options and initiatives. DESIGN: Cross-sectional, mailed survey. SETTING: Ontario family practices. PARTICIPANTS: Residency-trained Ontario family physicians (395 of 564 eligible physicians replied) who were certified between 1989 and 1991. MAIN OUTCOME MEASURES: Extent of approval or disapproval for 14 health policy options and initiatives. RESULTS: A 70% response rate was achieved. More than half of surveyed physicians expressed approval for shifting resources from acute care into preventive care and health promotion (71.6% approved), stricter immigration requirements to limit licensing of foreign physicians in Canada (60.4%), offering physicians salaries as an alternative to fee-for-service (54.0%), and incentives to physicians who wish to practise in community health centres or other forms of salaried group practice (51.1%). Some diversity of opinion was associated with sex, type of practice, primary source of remuneration, and practice location. CONCLUSIONS: These new-to-practice family physicians display diverse views and should not be seen as sharing a single opinion of health care policy options and initiatives. Many approve of changes to the health care system or are willing to consider policy alternatives.
A 2-year study has been completed to examine the dental health and patterns of treatment of samples of children registered under capitation in three areas of England. The opportunity was taken to compare some of these results with those reported in the same areas in 1989 when the dentists were remunerated under fee-for-service. In addition, the validity of the dental health information supplied by general dental practitioners on the FP17C form was assessed. The dental health of 14-15-year-old patients registered for more than a year was compared with that of similar patients in the same areas in 1989. There was a large reduction in the caries experience (mean DMFT) in these patients in all areas between 1989 and 1994 mainly due to a significant fall in the mean numbers of teeth filled. The mean number of teeth extracted for caries remained low in all areas. There was a small increase in the mean number of decayed, untreated teeth in all areas. There was a large increase in the proportion of patients with one or more fissure sealants present. The dental health of 7-8-year-old patients registered for more than a year was examined but, as this age group were not examined in 1989, no comparative data were available. Regularly attending child patients had, on average, one untreated decayed deciduous tooth, but few had more than two. Caries experience in first permanent molars was low in all areas. Data were collected from a sample of general dental practitioners in three areas on the treatment provided over a 12-month period for random samples of patients in two age groups: 6-12 and 13-15 years. There was an increase in two of the three areas in the provision of oral hygiene instruction and dietary advice. The level of fissure sealant use was maintained or increased. There was a reduction in the numbers of both deciduous and permanent teeth filled. Fewer children had teeth extracted. The proportions of patients having bitewing radiography reduced. The mean number of both visits and check-up examinations reduced. There validation of the dental health information on the FP17C was carried out by comparing the data collected for 7-8 and 14-15 year old patients during the dental health examinations with that submitted by general dental practitioners on FP17C forms to the Dental Practice Board for the same children. For the permanent dentition, agreement was good for missing and filled teeth but poor for decayed, untreated teeth. For deciduous teeth, levels of agreement were generally poor except for filled teeth where it was fair.
Studies published in the dental literature have found, all too frequently, that dentists do not pay adequate attention to the design of cast removable partial denture frameworks. This study investigated removable partial denture design in Alberta dental practices. The authors considered various issues related to surveying, partial denture design, and provider education, as well as the possible collaboration of clinical dentistry with denturism in removable partial denture treatment. Although the study found that a significant proportion of Alberta's dentists get involved in designing the cast framework, relatively few undertake surveying. Instead, surveying tends to be deferred to dental technicians. As was the case in other studies, no clear reason for this trend emerged, and it appeared to be unrelated to remuneration or time utilization issues. Responding dentists perceived that their undergraduate education was adequate for providing removable partial denture care. The study also identified a need for small, hands-on continuing education courses. About half of the respondents indicated that it is appropriate for dentists to collaborate with denturists on complete denture care. However, very few respondents considered it appropriate to refer to, or collaborate with, denturists in removable partial denture care.
According to French law, the collection of blood and the separation of plasma by apheresis may only be carried out in ETS licensed by the AFS. The major objective of the recent law is to reinforce and control the safety of blood transfusion and drugs. Plasma donation is based on ethical principles of anonymity, non remuneration and voluntary agreement of the donor. In 1994, the plasma requirements for fractionation were satisfied, with plasmapheresis covering 28%. Since fractionation of French plasma is performed solely by the LFB, the evolution of the use of immunopurified factor VIII will govern future plasmapheresis activity. The number of plasmapheresis donors could potentially be increased in this country, especially if immunopurified factor VIII can be prepared under licence by the LFB. Thus collaboration between public and private industry will be essential to enable France in the future: i) to produce immunopurified factor VIII from plasma collected in the ETS instead of importing the same product prepared abroad from foreign plasma, ii) to contribute to European self-sufficiency and iii) to develop the collection by plasmapheresis of specific plasma for the production of specific immunoglobulins.
BACKGROUND: All UK medical schools are revising their curricula following the General Medical Council recommendations to increase general practice involvement in undergraduate education. However, workload in general practice has increased in recent years, raising questions about its ability to maintain, let alone extend, its educational activities. AIM: The aim of this study was examine whether recent changes in general practice have affected delivery of practice-based undergraduate education and to assess the extent to which practices will be able to increase their involvement in teaching. METHOD: A postal questionnaire survey was conducted of the lead clinical teachers and their partners in the practices to which students from Leicester Medical School had been attached in the last 2 years. RESULTS: The questionnaire was completed by 32 out of the 39 lead teachers and 134 of the 150 partners, an overall response rate of 88%. There was widespread support for departmental teaching requirements, but only 17 lead teachers (44%) felt that the suggested reduction by 25% of patients seen per session while teaching was feasible. A total of 14 lead teachers (47%) felt that the ability of their practice to deliver high-quality teaching had declined since 1990. Altogether, 113 (87%) of all doctors in teaching practices felt that time pressures had increased during this period, and 139 (88%) felt that present levels of remuneration were inadequate. The majority of these doctors felt that general practice was the preferred location for learning generic clinical skills and were interested in participating. Nevertheless, most were not prepared to increase their involvement in teaching under present arrangements. CONCLUSION: Practice-based teachers appreciate the need for quality teaching, remain enthusiastic about teaching and are, in principle, willing to take an increased teaching load. However, recent changes have made delivery of teaching more difficult, and if an expansion in practice-based teaching is to occur, more realistic levels of funding and support are a prerequisite.
Academic people devote themselves too rarely to an analysis of the evolution in a profession for which 80% of its students are intending to take up, that is, a dispensing chemist. This article is divided into three parts: the first part is an analysis aiming at understanding a certain moroseness felt by dispensing chemists in a society which is evolving. The pharmacy faculties, very centred on themselves, preoccupied about their scientific recognitions, are more and more getting away from the field professionals, both by their teaching and by their research. This leads the profession to a distress where everyone plays in one's camp, with the author's feeling of seeing some teachers sawing the branch of which they are seated. The pharmaceutical profession is itself under the stress of attacks from the ministry through the decrease of remunerations as part of the health expenditure control and from supermarkets which are delight to be able to open breaches into parapharmaceutical fields. How is it possible to reconcile the university and the chemist's shop.
The German health care system is characterized by three trends that will continue into the next millennium: lasting restriction of financial resources, extension of remuneration systems with rationalization incentives; shift of responsibility from the state towards self-administration. These are illustrated by examples. The fundamental positions of the relevant political parties are basically similar. Medical quality assurance measures will grow more important. The adaptation process will only be possible on a step-by-step basis. Physicians have a key role. The major medical organizations are willing to cooperate constructively. This is proof of a great sense of responsibility, but also of the realization that shaping the future is better than standing aloof.
The austerity legislation passed September 13, 1996 as well as the additional austerity measures pending for the field of rehabilitation in the framework of legislation aimed at refocusing self-government and self-responsibility in the statutory health insurance scheme (1. und 2. Gesetz zur Neuordnung der Selbstverwaltung und Eigenverantwortung in der gesetzlichen Krankenversicherung-1st and 2nd GKV-NOG) are going to jeopardize insurees' provision with medical rehabilitation generally. For 1997 alone, economies totalling some 3.2 billion DM have been legislated. By drastically increasing the additional payments to be made, the insured are to an intolerable extent being subjected to contributing towards the cost of their medical treatment. What is more, the 2nd GKV-NOG is to enable health insurance funds to totally exclude rehabilitation benefits from the standard catalog of benefits to be provided. Along with these spending limitations in the social insurance schemes, additional burdens have been imposed on the insured in gainful employment under regulations in the field of labour law effective as of October 1, 1996 applicable in case of participation in an in-patient rehabilitation measure. Thus, the employer is entitled to make deductions with regard to an employee's claim to continued remuneration during sick leave as well as part of his annual paid recreational leave for the duration of the inpatient rehabilitation measure. The population most adversely affected by this policy are those with chronic illness and disability.
As salvaging autologous transfusion(SAT) is conducted by employing blood lost by the patient during surgery, the limits of its clinical use are automatically determined. A thorough understanding of the characteristics and problems of SAT to reduce complications and to avoid the use of homologous blood should lead to the expansion of its clinical use. To achieve an expansion of SAT's use the following steps should be taken. Combining of SAT with another method of autotransfusion, increasing of the preoperative blood volume(volume of erythrocytes), prevention of destruction of erythrocytes in the process of bleeding, salvaging, cleaning and concentration (improvement in the rate of salvaging), preservation of the function of the erythrocytes obtained, immediate salvaging of blood by reduction in the processing time, improvement in the salvaging rate, recycling of the plasma substance separated in the process, removal of mixed harmful substances(malignant tumor cells, urine, bacteria), extension of indications, extension of subjects for whom SAT may be used to children, increase in the remuneration point in the Health Care System, and improvement in the limits of hemodilution of the organic body.
BACKGROUND: General practice is the focal point of primary care. There are national differences in the structure and organization of practice, the relationship with secondary care is being redefined, and in some countries major changes are taking place. AIM: To describe and examine differences in the service profiles of general practitioners (GPs) in European countries. METHOD: Standardized questionnaires in the national languages were sent to samples of GPs in 1993. Four areas of service provision were measured: the GP's position in the first contact with selected health problems, the involvement in minor surgery and the application of medical procedures, disease management and preventive care. The importance of the gatekeeping role, remuneration system, and geographical region in Europe was examined by comparing scores in appropriate national groupings. RESULTS: Data were received from 7233 GPs in 30 countries. Most national samples were random and the average response rate was 47%. In countries where GPs have a gatekeeping role, they had a relatively stronger position as doctors of first contact. In those countries where GPs were usually self-employed, they had a stronger role in disease management and screening for blood cholesterol. In the examination of the three structural elements of health care, the most striking differences were evident in the comparison between eastern and western Europe. GPs throughout Europe had a comparatively small role in organized health education. CONCLUSION: The position of GPs is weak in eastern Europe and some Mediterranean countries, where service profiles have a limited range. General practice was more comprehensive where the doctors had a gatekeeping role.