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PubMed2004

A historical context of municipal solid waste management in the United States.

Municipal solid waste management (MSWM) in the United States is a system comprised of regulatory, administrative, market, technology, and social subcomponents, and can only be understood in the context of its historical evolution. American cities lacked organized public works for street cleaning, refuse collection, water treatment, and human waste removal until the early 1800s. Recurrent epidemics forced efforts to improve public health and the environment. The belief in anticontagionism led to the construction of water treatment and sewerage works during the nineteenth century, by sanitary engineers working for regional public health authorities. This infrastructure was capital intensive and required regional institutions to finance and administer it. By the time attention turned to solid waste management in the 1880s, funding was not available for a regional infrastructure. Thus, solid waste management was established as a local responsibility, centred on nearby municipal dumps. George Waring of New York City organized solid waste management around engineering unit operations; including street sweeping, refuse collection, transportation, resource recovery and disposal. This approach was adopted nationwide, and was managed by City Departments of Sanitation. Innovations such as the introduction of trucks, motorized street sweepers, incineration, and sanitary landfill were developed in the following decades. The Resource Conservation and Recovery Act of 1976 (RCRA), is the defining legislation for MSWM practice in America today. It forced the closure of open dumps nationwide, and required regional planning for MSWM. The closure of municipal dumps caused a 'garbage crisis' in the late 1980s and early 1990s. Private companies assumed an expanded role in MSWM through regional facilities that required the transportation of MSW across state lines. These transboundary movements of MSW created the issue of flow control, in which the US Supreme Court affirmed the protection of garbage under the Commerce Clause of the Constitution. Thus MSWM in America today is largely managed by municipalities, and operated by a relatively small number of private companies. It consists of a mixture of landfill, incineration, recycling, and composting, and is regulated under RCRA, the Clean Air Act and other related federal and state laws.

Cities↗
PubMed2001

Medication errors in United States hospitals.

This study evaluated hospital demographics, staffing, pharmacy variables, health care outcomes measures (severity of illness-adjusted mortality rates, drug costs, total cost of care, and length of stay) and medication errors. A database was constructed from the 1992 American Hospital Association's Abridged Guide to the Health Care Field, the 1992 National Clinical Pharmacy Services database, and 1992 mortality data from the Health Care Financing Administration. Simple statistical tests and a severity of illness-adjusted multiple regression analysis were employed. The study population consisted of 1116 hospitals that reported information on medication errors and 913 hospitals that reported information on medication errors that adversely affected patient care outcomes. We evaluated factors associated with the 430,586 medication errors and 17,338 medication errors that adversely affected patient care outcomes. Medication errors occurred in 5.07% of the patients admitted each year to these hospitals. Each hospital experienced a medication error every 22.7 hours (every 19.73 admissions). Medication errors that adversely affected patient care outcomes occurred in 0.25% of all patients admitted to these hospitals/year. Each hospital experienced a medication error that adversely affected patient care outcomes every 19.23 days (or every 401 admissions). The following factors were associated with increased medication errors/occupied bed/year: lack of pharmacy teaching affiliation (slope = 0.8875, p=0.0416), centralized pharmacists (slope = 1.0942, p=0.0001), number of registered nurses/occupied bed (slope = 1.624, p=0.032), number of registered pharmacists/occupied bed (slope = 25.0573, p=0.0001), hospital mortality rate (slope = 2.8017, p=0.0192), and total cost of care/occupied bed/year (slope = 0.01432, p=0.0091). Factors associated with decreased medication errors were location in the Mid-Atlantic census region (slope = -1.5182, p=0.03), affiliation with a pharmacy teaching program (slope = -1.0252, p=0.0349), decentralized pharmacists (slope = -0.9843, p=0.0037), and number of medical residents/occupied bed (slope = -1.478, p=0.0014). There was a 45% decrease in medication errors (1.81-fold decrease) in hospitals that had decentralized pharmacists, compared with hospitals that had centralized pharmacists. In addition, there was a 94% decrease in medication errors that adversely affected patient care outcomes (16.88-fold decrease) in hospitals that had decentralized pharmacists compared with hospitals that had only centralized pharmacists. Based on previous field studies and our findings in 1116 hospitals, it appears that one of the most effective ways to prevent or reduce medication errors is to decentralize pharmacists to patient care areas. The results of this study should help hospitals reduce the number of medication errors that occur each year.

Education, Pharmacy↗
PubMedDate not supplied

Federal budget helps drive health policy. A close-up look at the budget process and how it affects health care funding.

Crafting the budget is an annual process that Congress and the administration use to define the national policy agenda. It is a massive undertaking to decide how more than two trillion dollars is spent by the federal government. Over 20 percent of the budget is used for health care. The budget is a political document that defines the priorities of the federal government and directly influences overall health policy. Its construction deserves to be followed and influenced by physicians to ensure the health of the public.

Budgets↗
PubMed1999

The changing landscape of health care financing and delivery: how are rural communities and providers responding?

Rural communities have not kept pace with the recent dramatic changes in health care financing and organization. However, the Medicare provisions in the Balanced Budget Act of 1997 will require rural providers to participate in the new systems. Case studies revealed the degree of readiness for change in six rural communities and charted their progress along a continuum, as reflected in three sets of activities: the development of networking; the creation of new strategies for managing patient care; and the adoption of new methods for contracting with health insurers. Some communities had constructed highly integrated systems, whereas others were just beginning to change their billing practices; a few were signing contracts for capitated care, in contrast to those that were resisting discounts in current fee structures. These six rural areas still have considerable ground to cover before their health care organization and financing reach the levels achieved by urban communities.

Aged↗
PubMed1977

Conflict and detente between social issues and clinical practice.

The "dual nature" of the mental health profession--embodied in the differences between advocates of social and clinical approaches to people's problems--is considered. It is suggested that the situation reflects realities of the world we live in, and that it contains both dilemma and opportunity. Areas in which social advocacy and clinical expertise have complemented each other are illustrated, and possibilities for constructive and creative conflict are suggested.

Child Abuse↗
PubMed1977

Establishment of two group practice centres by conversion of existing houses.

A practice of five (later six) doctors established their own group practice centre by purchase and conversion of an existing house. Later a second, smaller centre was established in the same way to replace an existing branch surgery.The planning, financing, and execution of these projects is described.

England↗
PubMedDate not supplied

Physician executives strive for balance in their changing roles.

Many physicians are apprehensive about healthcare reform and what it will mean for them. As physician executives, our job is to help construct systems that cost-effectively deliver high-quality services and achieve positive outcomes in a competitive environment. To this end, we must understand management and all of its ramifications--from finance to organizational dynamics to marketing to systems thinking and information management.

Career Mobility↗
PubMed2003

The construct validity of the client questionnaire of the Wisconsin Quality of Life Index--a cross-validation study.

The Wisconsin Quality of Life Index (W-QLI, Becker, Diamond and Sainfort, 1993) consists of eight scales: satisfaction with life domains, occupational activities, symptoms, physical health, social relations/support, finances, psychological wellbeing, and activities of daily living. The W-QLI has been modified to fit the characteristics of the Canadian population, the universal Canadian health system, and community and social services in Canada and the modified form was named CaW-QLI (Diaz, Mercier, Hachey, Caron, and Boyer, 1999). This study will verify the empirical basis of these theoretical dimensions by applying a cross-validation procedure on two samples, most of whose subjects have a serious mental illness. Confirmatory factor analyses and exploratory factor analyses using the principal component extraction technique with varimax rotation were applied. With the exception of the occupational activities domain, the remaining scales were correctly identified by the factor analyses on each sample. The occupational activities scale should be developed by additional items for representing this scale, which is too brief, and two other items should be revised in order to improve the quality of the instrument.

Adult↗
PubMed2004

Future trends in cancer therapy with particle accelerators.

Hadrontherapy is the radiotherapy technique that uses protons, neutrons or carbon ions. Protons and ions, being, heavy' charged particles, allow a more, conformal' treatment than X-rays and thus spare better the surrounding healthy tissues. By now about 35,000 patients have been treated worldwide with protons and about 1,600 with carbon ions. Since few years protontherapy of deep-seated tumours is booming with two hospital centres running in USA and three under construction. Four centres are treating patients in Japan. The list of constructions going on elsewhere is long: two in China, one in Germany, one in Korea, one in Switzerland. But the future hopes for a qualitatively different radiotherapy are centred on carbon ions: they have a larger biological effectiveness than X-rays and protons and are particularly suited to treat radio resistant tumours, as indicated by the encouraging results obtained on about 1,400 patients in HIMAC (Chiba, Japan) and on about 200 patients at GSI (Darmstadt). Two carbon centres are under construction in Europe: one (designed by GSI) in Heidelberg (Germany) and the other (designed by the TERA Foundation, in collaboration with CERN and INFN) in Pave (Italy). Other projects are moving towards the financing phase in Wiener Neustadt (Austria), Lyon (France) and Stockholm (Sweden). The five European projects are collaborating in the framework of ENLIGHT, the European Network for Light ion Therapy.

Forecasting↗
PubMed1992

Environmental justice, regulation, and the local community.

This article examines the sociological significance of the concept of "environmental justice" for grassroots groups responding to toxic contamination in their local communities. Taking into account nationwide mobilization patterns in such communities, the author documents a precedent-setting episode in the city of Jacksonville, Arkansas, where citizen protests and support from national environmental groups led the Environmental Protection Agency to withdraw three Technical Assistance Grants inappropriately awarded to a group with links to a polluting industry, and subsequently to rewrite the rules for participation in such grants. As the first such challenge nationally, the Jacksonville scenario is an important "test case" and permits a theoretical and practical evaluation of the relationship between social groups, technology, and the governmental regulatory process. More particularly, it gives insight into the Technical Assistance Grants program, which was set up to enable citizens living close to contaminated sites to interpret and evaluate technical information relating to such sites, but which has been undercut by a weak EPA and cooptation efforts by industries. The article concludes with an exploration of the concept of community in relation to the new construction of environmental justice engaged in by grassroots groups fighting contamination locally and nationally.

Arkansas↗
PubMed1991

[Utilization of the National Hospital 1985-89. How many beds should there be in a new National Hospital?].

The Norwegian Parliament (Stortinget), has approved a proposal for construction of a new national hospital in Oslo. White Paper no. 38 (1987/88) proposes a hospital with 610 beds. The number of inpatient days at the present Rikshospitalet (The National Hospital) has declined by 19.4% during the period 1985 to 1989. In 1989 the use of inpatient services was equivalent to 530 beds with an occupancy rate of 80%. Based on an assumed further reduction in hospital use in the years to come, we estimate the need for beds to be 340 at the new national hospital. This lower number is assumed to cover local hospital functions (54 beds), regional hospital functions (220 beds) and national services (65 beds). The authors assert that the White Paper is based on outdated assumptions. The construction of a 610-bed national hospital involves a health care structure which could obstruct the reorganization of hospital care (more use of outpatient services) elsewhere in Norway. The County Councils responsible for financing hospitals will be forced to fund a hospital use that is motivated essentially by teaching and research rather than by caring for patients.

Bed Occupancy↗
PubMedDate not supplied

Does the architectural design of burn centers comply with the Americans with Disabilities Act?

Title III of the Americans with Disabilities Act (ADA) requires that hospitals and burn centers be designed and constructed so that all public and common-use areas are accessible. At least 10% of patient bedrooms and toilets must be accessible to persons with mobility disorders. The purpose of this study was to determine whether four hospitals with burn centers complied with Title III of the ADA. The burn centers agreed to participate in this study only if they were first assured anonymity, because of the Health Care Financing Administration of the U.S. Department of Health and Human Services requires that each hospital comply. With use of the ADA accessibility guidelines, we developed a survey instrument that was validated by a state government building inspector. This tool was used to inspect the burn center facility and common use areas in four hospitals with burn centers. In the four hospitals, numerous architectural barriers to persons with disabilities were noted. No burn center had a designated accessible room for persons with disabilities. The bedrooms, bathrooms, sinks, bathtubs, and toilets were not accessible to persons with disabilities. The common-use areas in the hospitals, in contrast, had few architectural barriers to persons with disabilities. Only one burn center had plans to eliminate architectural barriers in its hospital. Because the four hospitals with burn centers had numerous architectural barriers for persons with disabilities, it can be concluded they do not comply with Title III of the ADA and are subject to severe penalty from the Health Care Financing Administration and the U.S. Department of Justice.

Architectural Accessibility↗
PubMed2001

Cost-effectiveness of universal cystoscopy to identify ureteral injury at hysterectomy.

OBJECTIVE: To evaluate the cost-effectiveness of routine cystoscopy at the time of abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy in terms of cost per ureteral injury identified and treated. METHODS: Using a hospital-based perspective, a decision-analysis model was constructed to estimate the outcomes and costs of cystoscopy or no cystoscopy at the time of abdominal hysterectomy. A similar model was constructed for vaginal and laparoscopically assisted vaginal hysterectomy to account for the cost of conversion to laparotomy. Cost estimates were based on estimated costs of Duke University Medical Center and from average Medicare reimbursements for similar Diagnostic Related Groups from the Health Care Financing Administration. The incidence of ureteral injury was obtained from a review of the literature. Sensitivity analyses were performed for the following variables: ureteral injury rate, silent ureteral injury rate, cost of cystoscopy, and cost of therapeutic interventions. We assumed a silent renal death rate of 0%. RESULTS: Routine cystoscopy at abdominal hysterectomy was cost-saving above a threshold ureteral injury rate of 1.5%. At a ureteral injury rate of 0.2%, the marginal increase in the cost of routine intraoperative cystoscopy was $108 per abdominal hysterectomy, with an associated cost of $54,000 per ureteral injury identified. In comparison, at a ureteral injury rate of 2%, routine cystoscopy gave a marginal cost savings of $44 per hysterectomy, with a cost savings of $2200 per ureteral injury identified intraoperatively. At the baseline ureteral injury rate of 0.5%, routine cystoscopy had a marginally increased cost of $83 per hysterectomy, with an incremental cost-effectiveness of $16,600 spent per ureteral injury identified. The model constructed for vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy yielded a threshold ureteral injury rate of 2%, above which routine cystoscopy was cost-saving. In both models, the incidence of ureteral injury and the cost of readmission were the two variables with the greatest influence on cost-effectiveness. CONCLUSION: The cost-effectiveness of routine intraoperative cystoscopy depends on the rate of ureteral injury independent of the route of hysterectomy. If that rate exceeds 1.5% for abdominal hysterectomy and 2% for vaginal or laparoscopically assisted vaginal hysterectomy, then routine cystoscopy is cost-effective.

Cost-Benefit Analysis↗
PubMed2001

Social capital, disorganized communities, and the third way: understanding the retreat from structural inequalities in epidemiology and public health.

The construct of social capital has recently captured the interest of researchers in social epidemiology and public health. The authors review current hypotheses on the social capital and health link, and examine the empirical evidence and its implications for health policy. The construct of social capital employed in the public health literature lacks depth compared with its uses in social science. It presents itself as an alternative to materialist structural inequalities (class, gender, and race) and invokes a romanticized view of communities without social conflict that favors an idealist psychology over a psychology connected to material resources and social structure. The evidence on social capital as a determinant of better health is scant or ambiguous. Even if confirmed, such hypotheses call for attention to social determinants beyond the proximal realm of individualized sociopsychological infrastructure. Social capital is used in public health as an alternative to both state-centered economic redistribution and party politics, and represents a potential privatization of both economics and politics. Such uses of social capital mirror recent "third way" policies in Germany, the United Kingdom, and United States. If third way policies lose support in Europe, the prominence of social capital there might be short lived. In the United States, where the working class is less likely to influence social policy, interest in social capital could be longer lived or could drift into academic limbo like other psychosocial constructs once heralded as the next big idea.

Community Health Planning↗