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PubMedDate not supplied

The hospice choice: ethical decision making.

Empirical research documents communication difficulties and practices which have contributed to clients' wishes and directives regarding end of life decisions being ignored, resulting in prolonged, painful deaths in hospital intensive care costs. Hospice decisions are complex end of life ethical decisions primarily because they are centered around client autonomy and the individual's right to choose to refuse treatment or to discontinue treatment. With documentation of the benefits of Hospice and palliative care, and overall client and family satisfaction reported in the literature, one has to question why more patients are not referred to Hospice, and why those who have been referred were done so at such a late date. A suggested model for analyzing end of life ethical decision making and contributing factors will be presented. It is a sociological, interactional model that will assist in identifying 'learned potential motivators' on the part of the client and the health care professional which can influence these individuals during decision making interactions and which can contribute to the 'rightness' or 'wrongness' of end of life decisions.

Choice Behavior↗
PubMed2003

Towards a european network for multiple sclerosis trials (ENMST).

Quality standards for clinical studies in the field of multiple sclerosis (MS) have improved significantly, to the great benefit of patients. This development has been accompanied by soaring costs and ever increasing complexity, with industry-independent trials having become virtually impossible. We propose establishing a European network that would include expertise in all the relevant aspects of MS treatment trials. In a stepwise approach, all interested active centres across Europe should be recruited into the network, based on agreement upon common scientific standards and quality requirements. Three main goals are discussed: to facilitate identification of potentially useful agents for MS treatment; to establish protocols for the interaction between investigators and industry; and to identify common standards and a core set of data to allow for comparisons of MS trials. Collaboration with existing international organizations and institutions, especially the Sylvia Lawry Centre for MS Research, as well as with similar initiatives in North America and other parts of the world is envisaged.

Clinical Trials as Topic↗
PubMed2006

[Hospital humanization as an expression of ethics].

The practice of health professionals in the hospital environment has been loosing its human characteristics in view of the care delivered to the disease rather than to the sick being, and also in view of the increasing technological complexity, associated with increasing costs. Ethics requires the implementation of a reflective process concerning the principles, values, rights, and duties ruling the practice of health professionals, the latter including the dimension of care from a humanized perspective. Thus, this study aimed to reflect on ethical considerations upon which humanization actions must be grounded, highlighting the importance of a human dimension in professional relations.

Ethics, Medical↗
PubMed2006

Instrumentation, control and automation for full-scale manure-based biogas systems.

In recent years manure-based biogas plants (MBBP) have won more and more importance, because of the numerous ecological advantages. The processes are similar to processes, which have been well known for many decades in anaerobic wastewater/sludge treatment. As a result of technical progress and permanently rising prices for non-renewable energy, MBBPs have become more and more economically reasonable. Because of the economies of scale law more and more larger MBBPs are being built (250-2000 kW(el)). With regard to investment costs, reactor volumes and complexity etc., these (centralized) plants are comparable with small wastewater treatment plants (WWTP). Consequently, as actually in the case of the small WWTPs a rising use of instrumentation, control and automation (ICA) for larger MBBPs can be observed.

Anaerobiosis↗
PubMed1997

Technical and economic models to support heifer management decisions: basic concepts.

To maximize herd profits, dairy farmers are faced with the complex dilemma of minimizing costs that are associated with rearing heifers while ensuring or enhancing lifetime economic productivity. Decisions about heifer management interact with underlying biological aspects of growth, thereby influencing future profitability. A thorough understanding of these biological interactions is lacking. Studies based on models could be useful in the evaluation of various rearing strategies. Currently available models for dairy cattle primarily focus on the dairy cow. In a dairy farm production system, management decisions concerning the rearing of livestock and the replacement of dairy cows strongly influence each other. In a model that describes the dairy herd as a multiple-component system, opportunity is greater to coordinate rearing and replacement policies. Expected benefits of such a model are discussed.

Animals↗
PubMedDate not supplied

Making the health care delivery system accountable.

Accountability has become the fact of life for the health care provider and the delivery system. Until recently, accountability has been viewed primarily through the judicial process as issues of fraud and liability, or by managed care entities through evaluation of the financial bottom line. It is this second consideration and its ramifications that will be explored in this article. Appropriate measurement tools are needed to evaluate services, delivery, performance, customer satisfaction, and outcomes assessment. Measurement tools will be considered in light of the industry's unique considerations and realities. All participants, including insurers, employers, management, and health care providers and recipients, bear responsibilities which necessitate assessment and analysis. However, until the basic question, "Who is the customer?" is resolved, accountability issues remain complex and obscured. Accountability costs and impacts must be evaluated over time. They go way beyond bottom line cost containment and reduction. Accountability will be accomplished when the health care industry implements quality and measurement concepts that yield the highest levels of validity and appropriateness for health care delivery.

Aged↗
PubMed1999

On suicide and suicide prevention as a public health issue.

Suicide is becoming one of the major causes of death especially amongst men. In Europe suicide is the second most common cause of death in the ages of 15-44 years. For women in the same age group suicide is the fourth most common cause of death. Suicide causes a lot of suffering not only in the victim but also in persons close to him. As the causative factors are complex, and suicide also costs the community a lot of money suicide and self destructive behavior must be considered an important public health issue. A couple of models which are helpful when trying to develop treatment and preventive strategies for suicided persons are presented. The basic principles for contemporary suicide prevention programmes are also described.

Adolescent↗
PubMed2001

Assessment of community mental health care in the Federation of Bosnia-Hercegovina (FBH) after the 1992-95 war.

Bosnia-Hercegovina is in the process of reforming its health care system. One realises that this is a complex matter that will cost a great deal of time and effort. The findings suggest that the highest priority now is the development of the 'mental health strategic and action 'plan', which includes (as a component of the overall PHC strategy) legislation, financing mechanisms, a clear statute for the CMHCs and staff, and to define the relationship with other PHC services. In addition, it is recommended that the authorities should take a more decisive co-ordinating and leading role. To this end, a special Mental Health Task Force assisted by a professional advisory group on mental health and/or professional consultants could be established. In order to realise a real cost-effective community-based care, it is inevitable to allocate enough funds to these primary mental health care services and initiatives such as sheltered living and family support initiatives (eventually to reallocate funds from expenditures on hospital-based care). A mental health reform does not happen in a vacuum and therefore can not be accomplished without 'negotiating' with other sectors/ministries, e.g., Ministries of Finances, Social Affairs/Displaced Persons and Refugees, International Trade and Economy. A multi-sector approach is considered indispensable. Overall management of CMHCs should be strengthened. In addition, it is important that CMHCs exchange information and promote standardised protocols and procedures to enhance comparability and structured referral. The planned Management Information System is a good example, but should be implemented as soon as possible in all CMHCs. Other initiatives to improve professional networking might include (community mental health) newsletters, round table conferences, etc. Further skills training of CMHC staff and management might be difficult to define as long as it is not clear what practical skills are required. Technical Assistance to the (mental) health sector should primarily focus on the overall framework and policy. Training should be tailored to the actual needs and focus primarily on local capacity building via training-of-trainers. Health prevention and promotion, i.e. information provision to the general public and community participation in terms of support for self-help groups and consumer groups, deserve more attention than it has received so far.

Bosnia and Herzegovina↗
PubMed1992

A review of military pilot selection.

Military pilot selection is a complex task involving huge cost in financial and human terms. In the United Kingdom, training a fast-jet pilot costs an estimated 3 million pounds and takes 3 years. Consequently, it is necessary that the training success rate be maximal, since failure not only represents financial loss but also wastage of human resources. Effective selection for flying training would be of special advantage at present, as the operational repertoire of military aircraft moves forwards. Personality-based selection appears to have limited value. Analysis of certain objective aptitude tests and monitoring of the learning curve appear more promising. The alternative of acquisition of flying skills through actual or simulated flying experience seems an expensive option. This paper reviews the development of selection methods and concentrates on those of current interest. Civilian aviation and other professional selection systems might also benefit from the military endeavors. The most exciting development is the linkage of computer technology and aptitude tests.

Aptitude Tests↗
PubMed2005

Future of operating rooms.

Operating-room design has not changed significantly since the modern era of surgery began. Minimal invasive, endoscopic, procedures, and evolution of technology will affect operating-room design in the near future. Poor ergonomics has always been one of the major drawbacks of endoscopic surgery. Use of retractable arms and monitors will improve ergonomics of the operating team. Developments in telecommunication will allow surgeons to communicate with colleagues and experts during the procedure in virtually any location around the world, which increases teaching possibilities and procedural safety. Introduction and further development of intraoperative imaging, including real-time, three-dimensional (3-D) reconstructions of patient, and computer-aided surgery offer surgeons the opportunity to train the planned surgical procedure. Moreover, they will improve control and supervision of the procedure in learning situations. The last decade's robotics have made their introduction into the operating rooms. They improve control over the operating-room environment and will facilitate the performance of more complex procedures. However, high costs and lack of force feedback remain its major drawbacks. Improvements of robotic techniques and its implementation into the operating rooms will further guide their design into highly specialized operating units.

Ergonomics↗
PubMed2006

Lifting the lid off of pricing. With HHS moving to post what it pays for common procedures, the debate over healthcare pricing transparency is heating up.

Healthcare pricing was the focus of discussion in Washington last week, with HHS announcing agencies will be posting the prices paid for common procedures, and industry experts testifying at a hearing on the topic. The debate among lawmakers tends to mask the complexity of shifting healthcare costs, says Paul Ginsburg, left.

Diagnostic Services↗
PubMed2006

Public-private partnerships for hospitals.

While some forms of public-private partnerships are a feature of hospital construction and operation in all countries with mixed economies, there is increasing interest in a model in which a public authority contracts with a private company to design, build and operate an entire hospital. Drawing on the experience of countries such as Australia, Spain, and the United Kingdom, this paper reviews the experience with variants of this model. Although experience is still very limited and rigorous evaluations lacking, four issues have emerged: cost, quality, flexibility and complexity. New facilities have, in general, been more expensive than they would have been if procured using traditional methods. Compared with the traditional system, new facilities are more likely to be built on time and within budget, but this seems often to be at the expense of compromises on quality. The need to minimize the risk to the parties means that it is very difficult to "future-proof" facilities in a rapidly changing world. Finally, such projects are extremely, and in some cases prohibitively, complex. While it is premature to say whether the problems experienced relate to the underlying model or to their implementation, it does seem that a public-private partnership further complicates the already difficult task of building and operating a hospital.

Contract Services↗
PubMed1988

Nuclear medicine: SPECT comparisons to PET.

Early comparisons between PET and SPECT imaging of the brain, therefore, confirm that SPECT is capable of revealing information about regional brain function and metabolism at a much lower cost and degree of complexity. While PET will continue to play a leading role in research, SPECT imaging will increasingly be used clinically to evaluate functional disorders of the brain.

Brain↗
PubMed1986

Recent developments in organizing and financing health-care services.

Recent developments in the organization and financing of health-care services are described. All recent developments reflect an effort by both private and public payers to restrict use of health-care services, as well as to control price. Private use-review programs, such as second-surgical-opinion services and case-management services, are increasingly being used. The number of hospital admissions and length of patient stay continue to decline, but, because of increasing complexity of care, the cost of pharmaceutical services has not decreased proportionately. Points relating to health-care financing in the federal reconciliation budget effective May 1, 1986, are reviewed, as are other new federal regulations affecting the structure of services and terms of reimbursement under the Medicare and Medicaid programs. For Medicare, these include new scope objectives for professional review organizations, decreased return-on-equity payments to for-profit hospitals for outpatient services and to skilled nursing facilities, and elimination of waiver-of-liability presumptions for hospitals. Also, physicians must now identify specific services provided during each inpatient hospital visit. Most developments related to home health-care services pertain to limiting the cost of durable medical equipment. Alternative types of health care based on capitation funding, such as health maintenance organizations, competitive medical plans, and preferred provider organizations, will continue to grow in both the public and private sectors, and the use of private use-review programs for controlling costs is expected to accelerate in the next year.

Delivery of Health Care↗
PubMed1987

[Suppression of factor VIII inhibitor in children with hemophilia A].

In 1977 Brackmann for the first time reported an induction of tolerance in hemophiliacs with inhibitors using a protocol requiring administration of very high daily doses of factor VIII and activated prothrombin complex concentrates. Since the costs of such a protocol are enormous, we report our experiences in 3 hemophiliac children with inhibitors against factor VIII treated with much lower doses of factor VIII concentrate only for induction of tolerance. Two "high responder" and one "low responder" initially for only a short period received factor VIII concentrate in doses comparable to the Brackmann protocol. After that period patients were treated with 25--30 units factor VIII concentrate/kg/day, doses that are comparable to conventional prophylactic treatment. In one high responder the inhibitor disappeared completely after 22 months, in the other high responder the inhibitor titer decreased from 133 BU to 4.4 BU. In the low responder also a significant decrease of the inhibitor titer was observed. At this time bleedings in all three patients can be controlled by conventional doses of factor VIII concentrate.

Adolescent↗
PubMedDate not supplied

The nursing instructor and clinical teaching.

Clinical teaching has long enjoyed a well deserved reputation as a difficult teaching challenge. Recent pressures, particularly those for accountability in health care, have accentuated the difficulties for clinical teaching. These pressures arise from public sensitivity to rising costs and the increasing complexity and sophistication of hospital systems (raising patient fears of technologies too complex to be understood). More than ever, patients insist on high quality care from all health profession workers. Thus, the increased frequency over the past 2 decades of articles on aspects of nursing quality is not surprising. How have these pressures affected the nursing instructor?

Clinical Competence↗
PubMed1979

Transportation: a key to independent living.

Accessible transportation is essential if people with disabilities, particularly persons who are severely disabled, are to live independently in the community. The development of transportation services has moved from a focus upon special and separate "dial-a-ride" programs to an emphasis upon making fixed-route, main-stream systems accessible. The current state of the art, supported in large part by federal regulations, features a combination of mainstream accessibility and supplemental special services. Future progress in transportation for disabled people depends largely upon resolution of complex, politically explosive cost-benefit arguments on the federal and local levels, and on community acceptance of disabled persons as people deserving a spectrum of transportation services.

Government Agencies↗
PubMed1982

[Physiologic stimulation: the future or a passing phase?].

Pacing techniques achieving normal AV synchrony are termed "physiologic". All rely on an atrial pacing or/and pacing system usually coupled with ventricular pacing. The major advantage is haemodynamic, usually related to the varying ventricular pacing rate obtained with atrial sensing systems only. Problems related to the more complex implantation technique, the cost of this system, its limited lifetime, more frequent iatrogenic complications and in particular the risk of reentry electronic "tachycardias" with the presently available models including an atrial sensing function, should limit the use of these devices to patients who really need AV synchrony if the implantation is technically possible, i.e., in our opinion, 10 to 15% of patients.

Arrhythmias, Cardiac↗