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[80 years' of internal medicine education at the medical school of the university in Belgrade (1922-2002)].

ORGANISATION OF TEACHING INTERNAL MEDICINE: The Department for Internal Medicine and Internal Clinics were founded in spring 1922. Dr. Radenko Stankovic and Dr. Dimitrije Antic were appointed as part-time Professors, while Dr. Aleksandar Ignjatovski, a former Full-time Professor of the Warsaw University, was appointed as professor under contract. A year later, Dr. Aleksandar Radosavljevic was appointed as Part-time Professor. In the General State Hospital and Military Hospital, certain wards were turned into clinics. II and III Internal Clinics were situated in the barracks, while the Propedeutic and I Internal Clinics were located in the Military Hospital. Upon the construction of the buildings of the Internal Clinic and General State Hospital, the Propedeutic and I Internal Clinics were permanently placed in the new building, and II and III Internal Clinics in the General State Hospital. Teaching of Internal Medicine started 31 October 1922. Dr. R. Stanko vic delivered a lecture in Propedeutics for students of the fifth term. This date marks the beginning of teaching internal medicine at the newly established School of Medicine, University of Belgrade. Dr. A. Ignjatovski started lecturing Internal medicine 23 March 1923, whereas Dr. D. Antic and and Dr. A. Radosavljevic also delivered lectures in the areas of Internal Medicine within their professional scope. At the beginning, the clinics belonged to the General State Hospital. It was impossible to teach successfully in hospital, therefore upon the professors' request, the clinics were separated and thus became the institutions belonging to the School of Medicine-educational institutions, while hospitals were health institutions. The rule was 'one professor--one clinic'. After the Second World War, teaching Internal Medicine was begun in demolished buildings in very difficult financial circumstances. The Propedeutic Internal clinic was renamed IV Internal Clinic, which continued dealing predominantly with cardiology. III and IV Internal Clinics were placed in the building of the Internal Clinic, II Internal Clinic remained in the General State Hospital and I Internal clinic was moved to the new building of the Institute for Oncology. REFORMS OF SCHOOL OF MEDICINE AND ITS CLINICS: Out of the School of Medicine, Veterinary Medicine, Pharmacy and Stomatology, the Grand Medical School was formed. After several years, it was closed down, and the schools were returned to the University. The most important alteration was made when, according to the Law, the Clinics were isolated from the School and proclaimed hospitals, health institutions and organised into the Clinical Centre of the School of Medicine, then University Clinical Centre, and finally the Clinical Centre of Serbia as the teaching base. Within city hospitals, later on Clinical Hospital Centres, the teaching bases for Internal Medicine and other subjects were established, with introducing self-management and the Law on Associated Labour with independent financing, there came hard times for the School of Medicine and Clinics. The Law had negative effects upon the Schools--University and it had to be abolished. The next step in the reform was merging of I and II Internal Clinics into the Internal B Clinic, within the Clinics, out of specialized departments for certain branches of Internal Medicine there were formed clinics (Clinic for Cardiology, Pulmonology, Endocrinology, Diabetes and Metabolic Diseases and so on). The Internal A Clinic was situated in the building of the General State Hospital and the Internal B Clinic in the building of the Internal Clinic, where there were also III and IV Internal Clinics. CONSTRUCTION OF CLINICAL CENTRE: After a long time, there were created conditions for constructing a new building for locating clinics--the Clinical Centre, the foundation stone was laid 20 October 1976, and the first phase including the polyclinics was completed 1 January 1983. The preliminary concept of the bed capacity of 30 to 50 at Internal Clinics was altered and the Institutes were established. Firstly, the Internal Clinics was altered and the Institutes were established. Firstly, the Internal A and B Clinics were joined into the Basic Organisation of Associated Labour Internal Medicine. Afterwards, certain specialized Internal Clinics with respective surgical branches were linked and the Institutes were established (Institute for Cardiovascular Diseases, Institute for Pulmonology and Tuberculosis, Institute for Endocrinology, Diabetes and Metabolic Diseases and so on). The Institutes were located at the former buildings of the clinics as well as the vacant buildings of the Military Medical Academy, which moved into the new modern building at Banjica. Thus, Internal Medicine was organisationally closed down, while assistants and professors were gathered at the Department for Internal Medicine which represented the organisation for teaching Internal Medicine. Professors and assistants from certain specialized Institutes taught certain disciplines, and at the Clinical Hospital Centre bases where teaching staff was deficient, the Clinical Centre professors were of assistance. A colossal Emergency Centre was established within the Clinical Centre, providing services for the whole of the Republic and beyond, which is completely illogical since it should be the Republic Health Institution rather than the part of the Clinical Centre. Also, the Clinical Centre as the health institution is enormous and represents the teaching base. The first directors were lawyers and, as of recently, professors of the School of Medicine. By separating Clinics from the School of Medicine, teaching and allied staff have a double working status as unique, so financially more potent health sector has gradually pushed aside the teaching one being rather underestimated in such organisation. Ministers for Health and Directors of the Clinical Centre great executive power for appointing directors. There started an uprecedented systematic degradation of teaching staff, since assistant professors or newly appointed associated professors were appointed as managers over their own teachers, full-time professors. It is unusual that those young people accepted their big, delicate roles to manage their professors in front of whom they had taken their board exams or defended their masters' and doctoral theses in not so distant past. There has only been one case of a junior professor refusing to be the director of his own professor. The stationary section of the Clinical Centre including the Internal Clinics was completely constructed but has not been equipped or occupied yet. Deans were authoriZed, by the University Law, to appoint professors and assistants. Thus, a large number of them were appointed without any high scientific and teaching quality standards, and afterwards promoted, while certain highly competent professors were dismissed from the University. By altering the system and passing the new University Law, the situation has improved and the University is returning to its roots. Today, such Clinical Centre as the teaching base of the School of Medicine and the School itself represent a big problem, primarily the financial one. Thus, it will be very hard to re-establish the right relationship between these two institutions.

Education, Medical↗
PubMed2001

From diversity to unity. The classification of mental disorders in 21st-century China.

Psychiatric disease constructs represent social constructs and genuine states of distress that have biopsychosocial sources. As such, they have social uses peculiar to the social groups in which they are created and legitimized. This is as true in the United States as in the rest of the world. The DSM schema, for instance, is so organized that every possible mental condition is listed as a disease to legitimate remuneration to practitioners from private medical insurance and government programs. This particular social use may be irrelevant to other societies where health care is financed differently. The CCMD-3 system represents an attempt at global unification and preservation of features that are salient for local application. Compared with its previous editions, noticeable changes have been made to render it in tune with international usage. This remarkable speed of adaptation speaks to the global flows of information technology and China's openness under rapid economic reform. It also demonstrates that the middle-aged cohort of more pragmatic Chinese psychiatric leaders who headed the CCMD-3 task force are now less vulnerable to the domination of the most senior generation of Chinese psychiatrists. Having been trained in the Russian system of psychiatry and gone through the various periods of national shame that traumatized China, they used to be very cautious about adopting foreign technology in general. This is why much less harmonization with the ICD-10 occurred with the CCMD-2-R, when the responsible task force was, for better or worse, dominated by these senior psychiatrists. Nonetheless, as Stengel and Sartorius remarked, an international classification must not aim to oust or replace regional classifications that serve valuable functions in the local contexts. No single classificatory system, Kirmayer submits, will suffice for all purposes--the correct diagnostic scheme is the one that accomplishes its explicit pragmatic aim by addressing the relevant level of description. The particular additions (e.g., travelling psychosis, culture-related mental disorders), deletions (e.g., depressive neurosis, pathologic gambling, avoidant and borderline personality disorders), retentions (e.g., unipolar mania, neurosis, hysteria, homosexuality), and epistemologic variations (e.g., somatoform disorder, neurasthenia) of diagnostic categories reflect exactly this simultaneous need to globalize and to take account of the changing reality of illness in contemporary China. Stengel advised that "no psychiatric classification can help being partly etiological and partly symptomatological, because these are the criteria by which psychiatrists distinguish mental disorders from each other." To an extent, the CCMD-3 is a critique of certain nosologic assumptions of Western psychiatry, such as the feasibility of a neo-Kraepelinian taxonomy grounded exclusively in symptomatology across all diagnostic categories, and the validity of syndromic architectures based on a firm adherence to the mind-body dichotomy. From this angle of vision, local systems of classification such as the CCMD-3 may offer an opportunity for needed reflections by North American psychiatrists who have simply taken the DSM-IV schema for granted. Sartorius reckoned that a classification is a way of seeing the world at a point in time. A deep study of the CCMD-3 is thus an avenue for achieving an understanding of the contemporary Chinese mind and the social realities in China. The remarkable diversity of China at present, namely, a Communist Party dominated state socialist political structure but the most rapidly growing capitalist economy in the world, guarantees that Chinese people's social and moral experience of illness will continue to change. The study of such culture-specific categories as travelling psychosis, neurasthenia, qigong-induced mental disorder, and dysfunctional homosexuality sheds light on the larger sociomoral processes and destabilizing changes in subjectivity that are occurring in this most populous country in the world.

China↗
PubMed1987

Capital intensive hospital technology and illness: an analysis of American state data.

This paper: describes the development of a 'hospital technology index' to measure the level of capital intensive medical technology in each of the 50 U.S. states and the District of Columbia, reports differences between states in scores on this index, and tests the hypothesis that there is a low but significant negative correlation between the level of capital intensive medical technology and the level of illness. The three subscales of the hospital technology index have high alpha coefficients of reliability, are reasonably orthogonal, and there is at least some evidence of construct and discriminant validity for each. The multiple regression analysis suggests that there is either no relation between capital intensive medical technology and the rate of illness or that there is a slight tendency for the illness rate to increase as the level of technology increases. Eight possible explanations for the findings are discussed.

Financing, Government↗
PubMed2005

Patients' perspectives on how idiopathic pulmonary fibrosis affects the quality of their lives.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a debilitating lung disease with a survival of only three to five years from the time of diagnosis. Due to a paucity of studies, large gaps remain in our understanding of how IPF affects the quality of patients' lives. In only one other study did investigators ask patients directly for their perspectives on this topic. Further, currently there is no disease-specific instrument to measure health-related quality of life (HRQL) in patients with IPF. A carefully constructed measurement instrument, sensitive to underlying change, is needed for use in clinical trials and longitudinal studies of patients with IPF. Before developing such an instrument, researchers must improve their understanding of the relevant effects of IPF on patients' lives. On a broader scale, to provide the best care for people with IPF, clinicians must appreciate--from patients' perspectives--how this disease affects various aspects of their lives. METHODS: We used focus groups and individual in-depth interviews with 20 IPF patients to collect their perspectives on how IPF affects their lives (with a focus on the quality of their lives). We then analyzed these perspectives and organized them into a conceptual framework for describing HRQL in patients with IPF. Next, we examined how well certain existing measurement instruments--which have been administered to IPF patients in prior studies--covered the domains and topics our patients identified. RESULTS: In our framework, we identified 12 primary domains: symptoms, IPF therapy, sleep, exhaustion, forethought, employment and finances, dependence, family, sexual relations, social participation, mental and spiritual well-being, mortality. Each domain is composed of several topics, which describe how IPF affects patients' lives. When we compared the content of our conceptual framework with the existing instruments, we found the coverage of the existing instruments to be inadequate for several reasons, including they may tap general areas of QOL or HRQL but not some areas that appear to be most directly affected by IPF, and they include items that are relevant to symptoms and effects of other respiratory diseases but not IPF. CONCLUSION: Collecting patients' perspectives and developing an organized inventory of the relevant effects of IPF on patients' lives provides valuable information for improving our understanding of the impact of this disease on patients and their loved ones. We believe our findings will help alert clinicians and researchers to IPF patients' experiences and concerns. Based on the comparison or our conceptual framework with the content of four existing instruments, it would appear that developing an IPF-specific measurement instrument is justified. Our conceptual framework for describing health-related quality of life in patients with IPF lays a solid foundation for constructing such an instrument.

Adult↗
PubMed1990

Hunger and undernutrition in the United States.

In the United States, where food is plentiful nationwide, detection of populations at risk of hunger and malnutrition must rely more on social and economic indicators than on physiological indices, important as these are. Large federal programs expanded or created after the 1969 White House Conference on Food, Nutrition, and Health were shown to be successful during the 1970s in reducing hunger and malnutrition as a massive social phenomenon, even though poverty conditions remained the same. Studies that apply our knowledge of nutritional and dietary requirements to construct a "market basket" of inexpensive, commonly used foods that meet the Recommended Dietary Allowances (RDA) and that set estimated minimum incomes as a multiple of the cost of such an "RDA-based market basket" plus the costs of other necessities would identify populations and families at risk and permit better targeting of food programs.

Child, Preschool↗
PubMed2001

The Expert Consensus Guideline Series. Treatment of behavioral emergencies.

OBJECTIVES: Behavioral emergencies are a common and serious problem for consumers, their communities, and the healthcare settings on which they rely to contain, assess, and ultimately help the individual in a behavioral crisis. Partly because of the inherent dangers of this situation, there is little research to guide provider responses to this challenge. Key constructs such as agitation have not been adequately operationalized so that the criteria defining a behavioral emergency are vague. The significant progress that has been made for some disease states with better treatments and higher consumer acceptance has not penetrated this area of practice. A significant number of deaths of patients in restraint has focused government and regulators on these issues, but a consensus about key elements in the management of behavioral emergencies has not yet been articulated by the provider community. The authors assembled a panel of 50 experts to define the following elements: the threshold for emergency interventions, the scope of assessment for varying levels of urgency and cooperation, guiding principles in selecting interventions, and appropriate physical and medication strategies at different levels of diagnostic confidence and for a variety of etiologies and complicating conditions. METHOD: In order to identify issues in this area on which there is consensus, a written survey with 808 decision points was developed. The survey was mailed to a panel of 52 experts, 50 of whom completed it. A modified version of the RAND Corporation 9-point scale for rating appropriateness of medical decisions was used to score options. Consensus on each option was defined as a non-random distribution of scores by chi-square "goodness-of-fit" test. We assigned a categorical rank (first line/preferred choice, second line/alternate choice, third line/usually inappropriate) to each option based on the 95% confidence interval around the mean rating. Guideline tables were constructed describing the preferred strategies in key clinical situations. RESULTS: The expert panel reached consensus on 83% of the options. The relative appropriateness of emergency interventions was ascertained for a continuum of behaviors. When asked about the frequency with which emergency interventions (parenteral medication, restraints, seclusion) were required in their services, 47% of the experts reported that such interventions were necessary for 1%-5% of patients seen in their services and 32% for 6%-20%. In general, the consensus of this panel lends support to many elements of recent Health Care Financing Administration regulations, including the timing of clinician assessment and reassessment and the intensity of nursing care. However, the panel did not endorse the concept of "chemical restraint," instead favoring the idea that medications are treatments for target behaviors in behavioral emergencies even when the causes of these behaviors are not well understood. Control of aggressive behavior emerged as the highest priority during the emergency; however, preserving the physician-patient relationship was rated a close second and became the top priority in the long term. Oral medications, particularly concentrates, were clearly preferred if it is possible to use them. Benzodiazepines alone were top rated in 6 of 12 situations. High-potency conventional antipsychotics used alone never received higher ratings than benzodiazepines used alone. A combination of a benzodiazepine and an antipsychotic was preferred for patients with suspected schizophrenia, mania, or psychotic depression. There was equal support for high-potency conventional or atypical antipsychotics (particularly liquids) in oral combinations with benzodiazepines. Droperidol emerged in fourth place in some situations requiring an injection. CONCLUSIONS: To evaluate many of the treatment options in this survey, the experts had to extrapolate beyond controlled data in comparing modalities with each other or in combination. Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide some direction for addressing common clinical dilemmas in the management of psychiatric emergencies and can be used to inform clinicians in acute care settings regarding the relative merits of various strategies.

Aggression↗
PubMed2025

Two decades of resistance surveillance by the British Society for Antimicrobial Chemotherapy: design, development, delivery, deficiencies and future directions.

The British Society for Antimicrobial Chemotherapy Antimicrobial Surveillance Project was established in the United Kingdom (UK) and Ireland in response to dissatisfaction with existing antimicrobial surveillance which, in the 1990s, was fragmented and poorly informative for clinical and public heath purposes. The model developed into an integrated Project that was novel in its management and financing, being a true collaboration between a medical charity, pharmaceutical companies and the laboratories contracted to perform the testing. Separate 'Programmes' within an overall 'Project' collected and tested community- and hospital-acquired respiratory and bloodstream infection isolates. Cooperation with public sector bodies allowed data collection from the Project to be compared to routinely collected data from National Health Service laboratories. Between 1999 and 2019 the Project delivered test results on almost 100 000 isolates, from 17 bacterial genera to 44 antimicrobial agents. The results were made available annually on a specially constructed web site. In this supplement, we summarize the data collected in a series of papers relevant to the two programmes, discussing the Project's strengths and deficiencies. Support for the Project declined in the period after 2010, and collection ceased after 20 years, its demise related to changing priorities within the partner organizations. However, the bacterial collection remains and is to be maintained to assist in future work in combating antimicrobial resistance.

United Kingdom↗
PubMed2003

Treatment of behavioral emergencies: a summary of the expert consensus guidelines.

OBJECTIVES: Behavioral emergencies are a common and serious problem for consumers, their communities, and the healthcare settings on which they rely, but there is little research to guide provider responses to this challenge. Key constructs such as agitation have not been adequately operationalized so that the criteria defining a behavioral emergency are vague. A significant number of deaths of patients in restraint has focused government and regulators on these issues, but a consensus about key elements in the management of behavioral emergencies has not yet been articulated by the provider community. The authors assembled a panel of 50 experts to define the following elements: the threshold for emergency interventions, the scope of assessment for varying levels of urgency and cooperation, guiding principles in selecting interventions, and appropriate physical and medication strategies at different levels of diagnostic confidence and for a variety of etiologies and complicating conditions. METHOD: A written survey with 808 decision points was completed by 50 experts. A modified version of the RAND Corporation 9-point scale for rating appropriateness of medical decisions was used to score options. Consensus on each option was defined as a non-random distribution of scores by chi-square "goodness-of-fit" test. We assigned a categorical rank (first line/preferred choice, second line/ alternate choice, third line/usually inappropriate) to each option based on the 95% confidence interval around the mean rating. Guideline tables were constructed describing the preferred strategies in key clinical situations. RESULTS: The expert panel reached consensus on 83% of the options. The relative appropriateness of emergency interventions was ascertained for a continuum of behaviors. When asked about the frequency with which emergency interventions (parenteral medication, restraint, seclusion) were required in their services, 47% of the experts reported that such interventions were necessary for 1%-5% of patients seen in their services and 32% for 6%-20%. In general, the consensus of this panel lends support to many elements of recent regulations from the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services), including the timing of clinician assessment and reassessment and the intensity of nursing care. However, the panel did not endorse the concept of "chemical restraint," instead favoring the idea that medications are treatments for target behaviors in behavioral emergencies even when the causes of these behaviors are not well understood. Control of aggressive behavior emerged as the highest priority during the emergency; however, preserving the physician-patient relationship was rated a close second and became the top priority in the long term. Oral medications, particularly concentrates, were clearly preferred if it is possible to use them. Benzodiazepines alone were top rated in 6 of 12 situations. High-potency conventional antipsychotics used alone never received higher ratings than benzodiazepines used alone. A combination of a benzodiazepine and an antipsychotic was preferred for patients with suspected schizophrenia, mania, or psychotic depression. There was equal support for high-potency conventional or atypical antipsychotics (particularly liquids) in oral combinations with benzodiazepines. Droperidol emerged in fourth place in some situations requiring an injection. CONCLUSIONS: To evaluate many of the treatment options in this survey, the experts had to extrapolate beyond controlled data. Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide some direction for addressing common clinical dilemmas in the management of psychiatric emergencies and can be used to inform clinicians in acute care settings regarding the relative merits of various strategies.

Journal Article↗
PubMed2002

Utilization of dental health services among middle-aged people in Sweden and Denmark.

In 1999, questionnaires were sent to random samples of 1001 Swedish citizens aged 55-79 years and 1175 Danish citizens aged 45-69 years. Various questions were asked concerning dental conditions, dental visit frequency per year, and money spent annually on dental care, etc. The objectives were to assess differences in the utilization of dental services and to compare out-of-pocket costs for dental care in Sweden and Denmark with control for age, gender, dental conditions and income. More than 80% of the subjects reported that a dentist had examined them less than 1 year previously. However, 77% of the Danes reported dental visits twice a year or more compared to 28% of the Swedes. Although the Danes reported a more frequent use of dental services, they had poorer dental conditions compared to the Swedes. Even though the Swedes used dental services less often than the Danes did, more subjects reported high 12-month out-of-pocket costs. In the present study, separate models were constructed for the two countries because there could be different mechanisms at play, as indicated by the results. The different insurance systems along with different degrees of commercialization in the two countries might be the most decisive factors in this context.

Age Factors↗
PubMed1976

Health planning in the United States: an old idea with a new significance.

This paper examines major features of the National Health Planning and Resources Development Act of 1974 (P.L. 93-641), a piece of legislation that would radically restructure the health planning system of the United States. The Act combines several, previously uncoordinated, health planning and health resources development agencies into one coordinated program. The program is to consist of statutorily restricted federal agency which will generally oversee the operation of the program, a state program directed by a consumer-dominated board and a series of locally based, generally private, nonprofit, consumer-dominated corporations ("Health Systems Agencies") which will carry the bulk of the planning functions. The resource development portion of the act grants funds for a variety of programs. These include both grants and loans (at very favorable interest rates) for medical facilities. In addition there are funds available for innovative projects which hold the prospect of improving health services and environmental conditions within the community. The act also provides the states and local organizations with substantial power over a large portion of the allocations made under the Public Health Act and specifies the process by which health planning must be carried out. Each local planning agency must design a long range health plan for its community and prepare a one-year plan for carrying out portions of the health system plan. These two documents then are used to create State Health plans, plans for construction, modernization or conversion of health facilities and criteria for judging the appropriateness of health services offered in the local areas and in each state. The act seems to create a mechanism whereby the health industry could be quickly converted into a heavily regulated industry. This regulatory process could be implemented in conjunction with national health insurance or by itself.

Financing, Government↗
PubMed2001

Voluntary associations for cancer patients in Sweden: supportive activities.

Our aim was to describe voluntary associations for patients with cancer in Sweden (n=108) and their activities, type and extent of member support, and the associations' collaboration with the health care system. A specially constructed questionnaire with structured and open questions was used for the investigation. The frequency of answers was 89%. The results show in the broadest sense that the associations have two missions. The direct patient-related mission concerns providing patients with support in the form of close proximity, approachability and through distribution of knowledge together with financial and practical support; the indirect patient-related mission deals with activities aimed at improving conditions for patients in general within the health care system and by influencing authorities as well as supporting family members and significant others and providing financing. The associations collaborate with the health care system, although they face difficulties in becoming 'sanctioned' and in establishing positive relationships with the health care community. The associations display a positive attitude towards their cause and the personal gratification that the voluntary work brings. In general, the findings indicate that the associations have a potential to help patients live and cope with their cancer disease.

Health Care Coalitions↗
PubMed1986

Medical technology and developing countries: the case of Brazil.

Developing countries, faced with severe resource limitations, are trying to develop modern health care services that deliver sensible medical technologies. Because of their lack of development, these countries must import much technology, while often lacking the expertise to make wise choices. In this article, the case of Brazil is examined. Brazil has shared many of the problems of other developing countries, including inadequate access of the population to health services, maldistribution and excessive use of technology, a relatively weak national industry for production of drugs and medical devices, a weak policy structure for dealing with medical technology, and little tradition of using research or policy analysis as a guide to action. Since the election in 1985 that returned Brazil to democratic rule, the government has taken active steps to address many of these problems. The example of Brazil is important for all of the developing world to examine and follow, where applicable. In addition, North American and European aid programs could play a much more constructive role in helping less developed countries develop their health care services. International organizations such as the World Health Organization must also be active in assisting such countries to improve their decisions concerning medical technology.

Brazil↗
PubMed2003

Evaluating the California Wellness Foundation's Health Improvement Initiative: a logic model approach.

The difficulties of conducting randomized trials to evaluate community-based initiatives have led some researchers to argue in favor of a case study "logic model" approach to evaluation. This article describes a case study logic approach adopted for the evaluation of one community initiative, the Health Improvement Initiative (HII) funded by the California Wellness Foundation (TCWF). The HII is a comprehensive, community-based initiative designed to improve population health by implementing and sustaining community-level systems changes. Nine communities received funding to create broad-based community coalitions (Health Partnerships) that were charged with developing and implementing action plans around systems change. The HII is being evaluated using a case-study logic-model approach that uses quantitative and qualitative data to construct indicators of coalition functioning, systems changes, and population health. By examining the relationship between these indicators over time, it should be possible to determine if any changes in intermediate or long-term outcomes are associated with Health Partnership activities.

California↗
PubMed2004

Feasibility and construct validity of the parent willingness-to-pay technique for children with juvenile idiopathic arthritis.

OBJECTIVE: To assess the feasibility and construct validity of the willingness-to-pay (WTP) technique for measuring health care preferences in families of children with juvenile idiopathic arthritis (JIA). METHODS: Parents were asked to estimate the monthly US dollar amount they would be willing to pay to obtain for their child the following hypothetical drugs: ARTHRO, which guarantees complete clinical response; and NO-STOM-ACHE, a drug that eliminates gastrointestinal (GI) symptoms. A yes/no question was used with random assignment of the starting bids. Parents who agreed to pay the starting bid were then asked whether they would be willing to pay 200% and then 400% of this initial bid. Socioeconomic data and information on medications, disease activity, patient physical function, wellbeing, and health-related quality of life (HRQOL) were obtained. RESULTS: Sixty-two families of children with JIA were interviewed. GI symptoms were present in 54%, and 53% of the children had joints with active arthritis or limited range of motion. Four parents (7%) were unwilling to pay anything for any of the studied medications. The mean amount (median; mean percentage of available family income) families were willing to pay was $395 ($300; 15%) for ARTHRO and $109 ($80; 4%) for NO-STOM-ACHE. Correlation and regression analysis supported that, adjusted for the available family income, the WTP for ARTHRO was associated with disease activity, pain, and the HRQOL of the patients. After correction for the starting bids and the available family income, the WTP for NO-STOM-ACHE was associated with the patient's HRQOL, pain, and the amount of GI discomfort. CONCLUSION: The WTP technique is feasible and has construct validity for measuring health care preferences for children with JIA. Relatively large WTP estimates support a possible important negative impact of the disease on families of children with JIA.

Adolescent↗
PubMed2003

Health and social benefits from improving community hygiene and sanitation: an Indian experience.

India is a country where Atomic Age and near Stone Age people co-exist. On one hand India has achieved development in many areas, but on the other hand there is still the practice of open defecation and manual cleaning of human excreta from bucket privies by scavengers. National sanitation coverage is only about 34% meaning that 66% of the population practises open defecation. Such unhygienic conditions lead to infections and high mortality and morbidity in the community. Low sanitation coverage could be due to lack of affordable sanitation technology and awareness or motivation. Although the sewerage system was introduced in India long ago, high operational and maintenance costs have prohibited it from being implemented in most towns and cities. Similarly, the cost of a septic tank is beyond most people, and disposal of undigested sludge from septic tanks remains a problem. In contrast, the pour-flush two-pit toilet (known as Sulabh Shauchalaya) is a low cost, socially acceptable and appropriate technology that does not require scavengers to clean the pits. Sulabh has converted and constructed over 1.2 million such toilets throughout India, making 240 towns scavenger-free. Liberated scavengers are thereby available to take up vocational training in various market-oriented trades enabling self-employment. The on-site/ decentralised systems of waste management has improved community health and hygiene, particularly in socially deprived groups, and reduced the financial burden of local government.

Defecation↗
PubMed1977

Associations of cancer site and type with occupation and industry from the Third National Cancer Survey Interview.

From the Third National Cancer Survey (TNCS) Interview Study of 7,518 incident cases, lifetime histories of occupations and industries were studied for associations with specific cancer sites and types while controlling for age, sex, race, education, use of cigarettes or alcohol, and geographic location. Lung cancer patients were found more often than expected among several categories including trucking, air transportation, wholesaling, painting, building construction, building maintenance, and manufacturing (furniture, transportation equipment, and food products). Controlling for cigarette smoking did not change these associations. Leukemia and multiple myeloma were associated with sales personnel of both sexes, whereas lymphomas and Hodgkin's disease were excessive among women working in the medical industry. Other associations included rectal cancer with several retail industries; prostate cancer with ministers, farmers, plumbers, and coal miners; malignant melanoma with school teachers; and invasive cervical cancer with women working in hotels and restaurants. Breast cancer patients were more common among women who were teachers or other professionals and who worked in business and finance (even after controlling for education). Many other findings are presented in detailed tables. Results are reported mainly as a research resource for use by other investigators doing work in this field. Suggestions are given for future studies.

Adult↗
PubMedDate not supplied

Prevention with tamoxifen or other hormones versus prophylactic surgery in BRCA1/2-positive women: a decision analysis.

PURPOSE: Recent randomized controlled trials have shown that tamoxifen and raloxifene may prevent invasive breast cancer. This decision analysis study compares the outcomes of chemoprevention with tamoxifen, raloxifene, or oral contraceptives with the outcomes of prophylactic surgery among women with high-risk BRCA1/2 mutations. PATIENTS AND METHODS: We used a simulated cohort of 30-year-old women who tested positive for BRCA1/2 mutations and constructed a Markov model with Monte Carlo simulations, incorporating cumulative breast and ovarian cancer incidence rates from the literature and survival figures from SEER data. We assumed that prophylactic surgery reduces ovarian cancer risk by 45% and breast cancer risk by 90%, that tamoxifen reduces invasive breast cancer risk by 49%, and that raloxifene has similar efficacy and safety in premenopausal and postmenopausal women. We used data obtained from high-risk women by a time trade-off questionnaire to calculate quality-adjusted life-years. We based our cost estimates for hospital and ambulatory care on Health Care Financing Administration payments, the SEER-HCFA database, and the Pharmacy Fundamental Reference. RESULTS: In our model, a 30-year-old BRCA1/2+ woman could prolong survival by 0.9 years (95% probability interval, 0.4-1.2 years) by having bilateral oophorectomy, 3.4 years (2.7-3.7 years) by having bilateral mastectomy, and 4.3 years (3.6-4.6 years) by having both procedures instead of surveillance alone. Chemoprevention with tamoxifen and raloxifene increased survival by 1.6 years (1.0-2.1 years) and 2.2 years (1.3-2.8 years), respectively. Chemoprevention yielded more quality-adjusted life-years than did prophylactic surgery, even when treatment was delayed to age 40 or 50 years. All these procedures were cost-effective or cost-saving compared with surveillance alone. DISCUSSION: Our model suggests that although surgery may yield more substantial survival and cost benefits, quality of life issues may make chemoprevention a more attractive option for young women at high genetic risk.

Adult↗
PubMed1998

Assessing the value of a new pharmaceutical. A feasibility study of contingent valuation in managed care.

OBJECTIVES: The authors assessed the feasibility and construct validity of the contingent valuation method for measuring the monetary value to healthy enrollees in a health maintenance organization of a new drug, filgrastim, as prophylaxis against febrile neutropenia after chemotherapy treatment for cancer. METHODS: A random sample of 220 enrollees from a closed-panel staff-model health maintenance organization who did not have cancer were interviewed. Chemotherapy, febrile neutropenia and filgrastim were described by video and decision board. Questions were asked in two different scenarios: (1) User-based: Assuming they were at the point of consumption and about to receive chemotherapy, what is the maximum they would be willing to pay to receive filgrastim? and (2) Insurance-based: Given they were at risk of cancer in the future, what is the maximum they would be willing to pay in additional monthly insurance premiums to add filgrastim to the plan? In a second insurance scenario where respondents were told that filgrastim was covered, what is the minimum reduction in premium that persons were willing to accept to relinquish coverage of the drug? A 2 x 2 factorial design was used to contrast two bidding algorithms to test for starting point bias and two 5-yearly prior risks of cancer, 1/200 versus 1/100. Main effects were tested by ANCOVA controlling for age, sex, health, and income. RESULTS: Demographics of experimental cells were similar. No evidence was found of significant starting point bias. For user-based questions, as expected, willingness-to-pay increases with febrile neutropenia risk reduction, but at a declining marginal rate. Despite careful presentation of information to respondents, willingness-to-pay for insurance was higher in the lower prior risk group. Consistent with previous contingent valuation studies, the authors of the present study found evidence that willingness-to-accept exceeds willingness-to-pay for coverage of the same benefit. CONCLUSIONS: An insurance-based contingent valuation study is feasible in a health maintenance organization. Construct validation evidence was encouraging, with the exception of the test for prior risk of cancer; however, this was a between-person contrast and may have been confounded by other factors.

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