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"Just get out a proposal," is a command that is heard all too frequently from the officers of an institution, notes this author. The result is a slap-dash replica of what should have been a carefully constructed piece. With advise on the do's and don'ts of proposal writing, the author explains how any fund raiser can reach what at first seemed an unobtainable goal.
OBJECTIVES: Well into the 20th century, elderly people relied on traditional means of support, such as children's financial contributions or continued labor force activity. After the institution of Social Security in the late 1930s, retirement--permanent withdrawal from the labor force with financial arrangements made for support--became an expected part of the life cycle of men 65 years and older in the United States. This research explores the extent of retirement and methods to finance it in the period just before Social Security became available. METHODS: The 1935-1936 Study of Consumer Purchases (SCP) contains information on demographic and economic conditions for 5,975 households. The SCP is a rich but underutilized source of data on household behavior. The data allow two definitions of labor force activity to be constructed; descriptive statistics identify factors associated with retirement. RESULTS: Alternative sources of support, such as pensions and investment income, have been thought to be relatively insignificant before the 1940s. This article shows that retirement in the modern sense appeared before state provision of support for aged persons. SCP data indicate considerable reliance on such financial instruments, a particularly noteworthy result given Depression conditions. Pension and investment income also helps identify persons who might report a gainful occupation but appear to have withdrawn from labor force activity, meeting a modern definition of retirement. DISCUSSION: The SCP, collected just as Social Security was enacted, reveals that nonfamilial sources of income like pensions and investments had begun to underwrite retirement without dependence on family members. Many older persons relied on these instruments for support in old age, and many did not have children present in their households. These results constitute evidence for an independent, nonfamily-based retirement before governmental provision of assistance through Social Security.
Performance-related budgets are the result of negotiated performance units per hospital multiplied by state-wide negotiated prices. Such hospital budgets contain profit chances and loss risks. Exceeding the contractual fixed amount leads to price reductions, falling below that amount leads to lower reimbursement. A consistent pricing system for basic and department performance units could solve the present problem of cost separation in Germany. A step in this direction is the definition of hospital department groups and the construction of an average department treatment case, which could be priced on an average cost base. In the long run, more flexibility according to pricing and budgeting can be developed. Competitive insurance companies should be free to find their own budgets so that a hospital can have several independent contractors.
The models outlined above represent alternative constructs for examining factors that may or may not influence human health in a positive manner. If the economic framework seems more theoretical than actionable, consider an alternative framework that has been advanced by the American Hospital Association and described in Table I. Regardless of the framework adopted, work to improve the health care system and its financing will be hard, irrespective of whether incremental or wholesale changes are made. What is important, however, is that a thoughtful approach be taken and the trade-offs of each decision carefully weighted. The health of the population of the state and the country depend on it.
Sir Bernard Tomlinson's report focuses on London's health services, but his proposals have major implications for the future of clinical research--not just in London but in the United Kingdom as a whole. They must be seen in the context of a widely perceived decline in British research and development which also threatens clinical research. This article examines the implications of Tomlinson's proposals and related strategies and recommends the construction of a research market for the patient costs of clinical research to complement the NHS market for patient services introduced in 1991. These arrangements would help sustain the clinical research base and guarantee excellence.
OBJECTIVES: To evaluate the willingness, reasons and perceived obstacles to prescription by international non-proprietary name (INN) among general practitioners (GPs) in private practice. Method A panel of private GPs practicing in South-eastern France was surveyed twice, 2 months before and 5 months after a new contract between the National Health Insurance system and GP associations (5 June 2002). The panel was constructed with a random sampling approach stratified according to age, sex, and size of the urban unit. RESULTS: Between March-April and November-December 2002, the percentage of GPs willing to prescribe according to INN rose from 76.2% to 89.7%. These physicians reported that their principal reasons for such prescription were the June agreement and concern about the finances of the Health Insurance system. The principal obstacles they mentioned were the complexity of prescription by INN (66%), lack of appropriate information and tools (47%), and patient reticence (41%). CONCLUSION: More effort must be devoted to providing adequate information to patients and GPs. GPs need better training, information, and tools to help transform their willingness into action.
The statutory health insurance reform law of 1993 had a serious impact on the management of university hospitals. Firstly, the phase of strict budget caps, new in and out patient services could only be introduced when compensated with the elimination of other services. Most universities have mastered this challenge. In the second phase, an entirely new system of hospital fees will be introduced. This will lead to a high degree of uncertainty on the financial situation of the university hospitals. The new regulation on hospital fees only insufficiently takes into consideration tertiary care hospitals. A severe loss of income has to be reckoned with. The funding of current subsidies for medical research, training, construction projects and big-ticket equipment is threatened by the fiscal budget crisis due to the current recession and the heavy financial burdens of the German reunification. Therefore fundamental reforms with regard to the statutory form, the form of ownership, the responsibilities of the university hospital, the organization of management and decision processes, the public service law and investment financing are all unavoidable.
The magnetic resonance imaging unit in Bristol has been housed in a new purpose-built centre, shared between three District Health Authorities, but operated entirely separate from the National Health Service. Inasmuch as this is thought to be a unique arrangement, the publication of its finances and statistics have been readily tabulated at the end of its first year's operation, and may be of interest to others planning a similar organization.
PURPOSE: This project was done to develop a mathematical model for optimizing composite predictors based on gene expression profiles from DNA arrays and proteomics. METHODS: The problem was amenable to a formulation and solution analogous to the portfolio optimization problem in mathematical finance: it requires the optimization of a quadratic function subject to linear constraints. The performance of the approach was compared to that of neighborhood analysis using a data set containing cDNA array-derived gene expression profiles from 14 multiple sclerosis patients receiving intramuscular inteferon-beta1a. RESULTS: The Markowitz portfolio model predicts that the covariance between genes can be exploited to construct an efficient composite. The model predicts that a composite is not needed for maximizing the mean value of a treatment effect: only a single gene is needed, but the usefulness of the effect measure may be compromised by high variability. The model optimized the composite to yield the highest mean for a given level of variability or the least variability for a given mean level. The choices that meet this optimization criteria lie on a curve of composite mean vs. composite variability plot referred to as the "efficient frontier." When a composite is constructed using the model, it outperforms the composite constructed using the neighborhood analysis method. CONCLUSIONS: The Markowitz portfolio model may find potential applications in constructing composite biomarkers and in the pharmacogenomic modeling of treatment effects derived from gene expression endpoints.
The growth of health services employment in the United States is modelled using ARIMA analysis, and related to the growth in total U.S. employment. It is argued that specific features of the medical care sector (licensed professional manpower, non-profit firms, third-party financing) create institutional rigidities which delay adjustment to macroeconomic conditions and other shocks. Tests of Granger causality and the pattern of coefficients in the cross-correlation function show that health services employment does lag other sectors of the economy by an average of 2 to 4 years. A Box-Jenkins transfer-noise function model between total and health employment is constructed and evaluated, and the impact dynamics of adjustment to Medicare and Medicaid are estimated.
OBJECTIVE: The purpose of this study was to analyse the construct validity and the concurrent validity of the EuroQol instrument (EQ-5D self-classifier, EQ VAS and EQ-5D indices), time trade-off (TTO) and contingent valuation (willingness-to-pay) for preference-based valuation of depressive health states. METHODS: A survey of a representative sample (N = 3522) of the non-institutionalised population aged 18 and above in Germany was conducted using the EQ-5D, TTO and contingent valuation as well as the SF-12 questionnaire. Construct validity was analysed by comparing 130 respondents in whom 12-month prevalence for major depression, minor depression, or dystimia according to DSM-IV was identified based on a version of the Composite International Diagnostic Interview (WMH-CIDI) to respondents without depressive disorders. Concurrent validity was analysed by assessing the correlation between these measures in the group with depressive disorders. RESULTS: In the group with depressive disorders, problems in all EuroQol dimension except for mobility were significantly more frequent, and mean values of all analysed preference measures except for willingness-to-pay were less favourable than in the group without depressive disorders (EQ VAS score 67 vs. 78; EQ-5D index [VAS] 83 vs. 94; EQ-5D index [TTO] 0.81 vs. 0.91; TTO 0.89 vs. 0.95; always p < 0.001). In the group with depressive disorders, EQ VAS score and EQ-5D indices were significantly correlated one with another (ranging from r = 0.63 to r = 0.92) as well as with the mental and the physical component scale of the SF-12 (ranging from r = 0.26 to r = 0.45) and with willingness-to-pay (ranging from r = - 0.20 to r = - 0.22); besides, willingness-to-pay was significantly correlated with TTO (r = - 0.46). CONCLUSIONS: The results of this study point to the construct validity and concurrent validity of preference measures in patients with depressive disorders.
Health research generates knowledge that can be utilized to improve health system performance and, ultimately, health and health equity. We propose a conceptual framework for health research systems (HRSs) that defines their boundaries, components, goals, and functions. The framework adopts a systems perspective towards HRSs and serves as a foundation for constructing a practical approach to describe and analyse HRSs. The analysis of HRSs should, in turn, provide a better understanding of how research contributes to gains in health and health equity. In this framework, the intrinsic goals of the HRS are the advancement of scientific knowledge and the utilization of knowledge to improve health and health equity. Its four principal functions are stewardship, financing, creating and sustaining resources, and producing and using research. The framework, as it is applied in consultation with countries, will provide countries and donor agencies with relevant inputs to policies and strategies for strengthening HRSs and using knowledge for better health.
This Law and regulatory Decree No. 2017 of 12 October 1988 (Diario Oficial, No. 38531, 12 October 1988, pp. 1-7) establish new procedures for the distribution of rural land in Colombia. A major aspect of these laws is the incorporation of the National Council of Economic and Social Policy (CONPES) into the planning and control of the agriculture reform scheme. According to these regulations, the Colombian Institute for Agriculture Reform (INCORA) will be in charge of the creation of the Annual Plan of Activities which establishes the regions subject to a land distribution plan under the supervision of CONPES. Once the Annual Plan of Activities is formulated, the regulations authorize INCORA to negotiate directly with the owners of the lands covered by the regional plan. For this purpose, the land is subject to technical analysis consisting of an on-site visit during which the quality, improvement, and value of the machinery attached to the land are assessed. After the analysis is completed, an offer will be made to the owner, who has a period of 15 days to accept or reject it. If the offer is rejected, INCORA will initiate an expropriation proceeding. Payment will be made in government bonds, maturing in five years. The owners have a right to seek the exclusion of their lots from regional plans. A second major aspect of these laws is that their objectives include not only the redistribution of the land but also the creation of adequate infrastructure for the development of regions subject to agrarian reform. Projects for the construction of railroads or other means of transportation, public service facilities, and cultural centers will be carried out keeping in mind the principle that respect for environmental concerns be maintained.
The Choices for Healthy Outcomes in Caring for End-Stage Renal Disease ([ESRD] CHOICE) Study was designed to evaluate the effectiveness of alternative dialysis prescriptions. As part of CHOICE, we developed an instrument for measuring health-related quality of life (HRQOL) for patients with ESRD that would complement the Medical Outcomes Study 36-Item Short-Form Survey (SF-36) and be sensitive to differences in dialysis modality (hemodialysis [HD] and peritoneal dialysis [PD]) and dialysis dose. The selection of HRQOL domains to be included was based on: (1) a structured literature review of 47 articles describing 53 different instruments; (2) content analysis of five focus groups with HD and PD patients, nephrologists, and other providers; (3) a survey of 110 dialysis providers about features of different modalities that affect patient HRQOL; and (4) a semistructured survey of 25 patients with ESRD on the effects of dialysis on functioning and HRQOL. To help prioritize domains and items identified by these methods, a representative sample of 136 dialysis patients rated each item for frequency and bother. A panel of nephrologists provided advice about the salience of items to modality or dose. Items and scales were selected with a preference for existing measures tested in patients with ESRD and were tested for reliability and validity. The first four steps yielded 22 HRQOL domains that included 96 items: 8 generic domains in the SF-36 (health perceptions, physical, social, physical and emotional role function, pain, mental health, and energy); 8 additional generic domains (cognitive functioning, sexual functioning, sleep, work, recreation, travel, finances, and general quality of life); and 6 ESRD-specific domains (diet, freedom, time, body image, dialysis access [catheters and/or vascular], and symptoms). New items were developed or adapted to assess ESRD-specific domains. Scales for these items showed adequate internal consistency (Cronbach's alpha > 0.70, except for time [alpha = 0.57] and quality of life [alpha = 0.68]), as well as convergent and discriminant construct validity in a sample of 928 patients. The final questionnaire included 21 domains (time was deleted) and 83 items. We have designed a patient-centered instrument, the CHOICE Health Experience Questionnaire, that addresses domains that may be sensitive to differences in dialysis modality and dose and shows evidence for reliability and validity as a measure of HRQOL in ESRD.
The overall design of burns units will depend on the required size and available finance. The Working Party has considered the optimal location and specific requirements of a unit, including dressing, operating and isolation rooms, intensive care and ancillary facilities. Various possibilities for ventilation systems in these areas have also been discussed.
"This paper studies the settlement of the immigrants from the poor areas of China in the aid-the-poor program, which is a government program providing assistance for poor areas of China. The layout and construction of the new immigrant community and the steps necessary for the creation of an immigrant settlement are also discussed in this paper."
The lack of a viable organizational typology is cited as a factor in the current absence of comparative research among physical rehabilitation facilities. A short discussion of approaches to typology construction is given which concludes that theoretically grounded typologies are most likely to produce useful insights. Subsequently, a fourfold typology of treatment facilities-maintenance, processing, changing and rehabilitation-is generated from a theory of variations in patient handling.
Health sector reform is a priority issue in many countries and there is great scope for an international exchange of experiences. We should not be amiss, however, to the problems and dangers of such international exchange. Focusing on the situation of developing countries, three critical problems are identified: tendencies to the universalism of a market approach, a one-way transmission of ideas, and the lack of policy analysis. In order to contribute to a more constructive process of international exchange, four recommendations are proposed in the areas of training and the approach to management, management research, strengthening health policy analysis, and developing new exchanges between countries.