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Shared and private variability in the auditory cortex.

The high variability of cortical sensory responses is often assumed to impose a major constraint on efficient computation. In the auditory cortex, however, response variability can be very low. We have used in vivo whole cell patch-clamp methods to study the trial-to-trial variability of the subthreshold fluctuations in membrane potential underlying tone-evoked responses in the auditory cortex of anesthetized rats. Using methods adapted from classical quantal analysis, we partitioned this subthreshold variability into a private component (which includes synaptic, thermal, and other sources local to the recorded cell) and a shared component arising from network interactions. Here we report that this private component is remarkably small, usually about 1-3 mV, as quantified by the variance divided by the mean of the ensemble of tone-evoked response heights. The shared component can be much larger, and shows more heterogeneity across the population, ranging from about 0 to 10 mV. The remarkable fact that, at least 5 synapses from the auditory periphery, this variability remains so small raises the possibility that the intervening neural circuitry is organized so as to prevent private noise from accumulating as neural signals propagate to the cortex.

Acoustic Stimulation↗

Private costs of patients hospitalized with community-acquired pneumonia.

BACKGROUND: Community-acquired pneumonia (CAP) is a condition which frequently requires hospitalization and consequently, can result in high costs. Little is known of the additional personal resources that are used by patients hospitalized for CAP. OBJECTIVE: To measure the private costs for persons who were hospitalized with CAP for the 30 days after being admitted to hospital using a systematic method of measurement. METHODS: Potential personal cost items were identified by nurses familiar with the treatment of CAP and categorized. Using telephone interviews in conjunction with the cost-identification framework, 60 patients from the Edmonton, Alberta area were surveyed for their private costs associated with CAP for 30 days after admission to hospital. RESULTS: Of the 60 patients surveyed, 49 were older than 65 years of age. The mean private cost was 505 dollars, which amounted to 5.6% of the total societal costs of 8,970 dollars. The distribution was skewed with a small number of patients that had high costs. CONCLUSIONS: This method allows the determination of the societal costs for patients hospitalized with pneumonia, and the costs were not much greater than those to the health care system.

Adult↗

Characteristics of assaultive patients in private hospitals.

A study of two large private psychiatric hospitals showed rates and patterns of assaultive behavior by patients comparable to those found earlier in a study of public hospitals; this was especially true in the hospital that admitted involuntary patients. The targets of assault were predominantly family members other than spouses or children and persons outside the family. Seclusion was commonly used to manage assaultive patients in the private hospitals and the seclusion rates were higher than those found for public hospitals, probably reflecting a staff preference for seclusion over heavy medication. The need for staff education and support in the management of assaultive patients exists in private hospitals as well as public hospitals.

Adult↗

Demographic and clinical characteristics of black psychiatric patients in a private general hospital.

A study of 419 first admissions to a private general hospital psychiatric inpatient unit showed that only 8.8 per cent were blacks, while 23 per cent of the population in the community were blacks. When compared to white patients, blacks were much less likely to be rerred for hospitalization by private sources, were substantially younger, and had shorter hospitalizations. The most common diagnosis for blacks was paranoid schizophrenia. The authors conclude that despite the widespread availability of third-party insurance coverage, blacks use the private general hospital less ofter than whites and their patterns of use are substantially different.

Adolescent↗

Short-term inpatient care and readmission rates: the CMHC approach versus the private approach.

Community mental health centers hospitalize patients for a significantly shorter time than do private psychiatric hospitals. Proponents of the private system of care assert that the shorter hospitalization contributes to an increased probability of readmission. A comparison of the readmission experience of CMHC patients and private patients who were hospitalized at the same institution showed no significant differences in the short-term recidivism rate. It is suggested that an aftercare network that is closely integrated with hospital care is a necessary supplement to brief hospitalization. In addition, it appears that restrictive reimbursement policies for outpatient care result in an increase in the duration of hospitalization and in the probability of rehospitalization.

Aftercare↗

Psychiatric findings among child psychiatric inpatients grouped by public and private payment.

OBJECTIVE: The study compared school-age psychiatric inpatients whose care was publicly funded with those whose care was privately funded to determine whether the public patients presented with more psychiatric risk factors and more psychiatric problems. METHODS: Retrospective chart review was used to collect data on the demographic and personal characteristics, behavior in the hospital, and response to milieu treatment of 40 public patients and 40 private patients. Half of each group were admitted during 1985-1986, and half during 1991-1993. Characteristics of the two groups were compared, and trends over time were examined. RESULTS: The public group presented for hospitalization with significantly more risk factors and psychiatric problems. Public status predicted the use of certain interventions, such as time-outs and physical holding. Public patients responded less positively to the treatment program. They had three times the number of bed-days as the private group during 1991-1993. CONCLUSIONS: Public patients require more intensive and extensive inpatient treatment and will be more profoundly affected by the restrictions on psychiatric inpatient care in the current climate of fiscal restraint.

Adolescent↗

Intensive care--is it possible in a private hospital?

Although sophisticated intensive care units have become universal in major public hospitals in Australia, this complex and expensive form of patient care is usually not available in independent private hospitals. Such a unit was recently established in a large private hospital which had expanded its facilities to encourage major surgery and its admission policies to include complex specialist medical problems. The unit's organisation included an appropriate physical area, comprehensive equipment, skilled nursing staff, resident medical staff, accredited medical specialists, and a common set of policies and protocols. In its first 12 months, the unit had 301 admissions, 82% of whom were surgical. Unit mortality was 3.3% and hospital mortality 6%. Patients were similar in age and sex distribution to those admitted to an intensive care unit in a public hospital but their numbers, type of illness, duration of admission and mortality differed. Despite the feasibility of establishing a sophisticated intensive care unit in a private hospital, there were potential problems related to staffing (especially insufficient numbers of trained nurses), funding (especially inadequacy of hospital and medical insurance and unavailability of many drugs on the Government's Schedule of Pharmaceutical Benefits) and relations with medical staff outside the unit.

Adolescent↗

Vendor-to-vendor education to improve malaria treatment by private drug outlets in Bungoma District, Kenya.

BACKGROUND: Private outlets are the main suppliers of uncomplicated malaria treatment in Africa. However, they are so numerous that they are difficult for governments to influence and regulate. This study's objective was to evaluate a low-cost outreach education (vendor-to-vendor) programme to improve the private sector's compliance with malaria guidelines in Bungoma district, Kenya. The cornerstone of the programme was the district's training of 73 wholesalers who were equipped with customized job aids for distribution to small retailers. METHODS: Six months after training the wholesalers, the programme was evaluated using mystery shoppers. The shoppers posed as caretakers of sick children needing medication at 252 drug outlets. Afterwards, supervisors assessed the outlets' knowledge, drug stocks, and prices. RESULTS: The intervention seems to have had a significant impact on stocking patterns, malaria knowledge and prescribing practices of shops/kiosks, but not consistently on other types of outlets. About 32% of shops receiving job aids prescribed to mystery shoppers the approved first-line drug, sulfadoxine-pyremethamine, as compared to only 3% of the control shops. In the first six months, it is estimated that 500 outlets were reached, at a cost of about $8000. CONCLUSIONS: Changing private sector knowledge and practices is widely acknowledged to be slow and difficult. The vendor-to-vendor programme seems a feasible district-level strategy for achieving significant improvements in knowledge and practices of shops/kiosks. However, alternate strategies will be needed to influence pharmacies and clinics. Overall, the impact will be only moderate unless national policies and programmes are also introduced.

Adult↗

Public - private 'partnerships' in health - a global call to action.

The need for public-private partnerships arose against the backdrop of inadequacies on the part of the public sector to provide public good on their own, in an efficient and effective manner, owing to lack of resources and management issues. These considerations led to the evolution of a range of interface arrangements that brought together organizations with the mandate to offer public good on one hand, and those that could facilitate this goal though the provision of resources, technical expertise or outreach, on the other. The former category includes of governments and intergovernmental agencies and the latter, the non-profit and for-profit private sector. Though such partnerships create a powerful mechanism for addressing difficult problems by leveraging on the strengths of different partners, they also package complex ethical and process-related challenges. The complex transnational nature of some of these partnership arrangements necessitates that they be guided by a set of global principles and norms. Participation of international agencies warrants that they be set within a comprehensive policy and operational framework within the organizational mandate and involvement of countries requires legislative authorization, within the framework of which, procedural and process related guidelines need to be developed. This paper outlines key ethical and procedural issues inherent to different types of public-private arrangements and issues a Global Call to Action.

Editorial↗

Financing and cost-effectiveness analysis of public-private partnerships: provision of tuberculosis treatment in South Africa.

BACKGROUND: Public-private partnerships (PPP) could be effective in scaling up services. We estimated cost and cost-effectiveness of different PPP arrangements in the provision of tuberculosis (TB) treatment, and the financing required for the different models from the perspective of the provincial TB programme, provider, and the patient. METHODS: Two different models of TB provider partnerships are evaluated, relative to sole public provision: public-private workplace (PWP) and public-private non-government (PNP). Cost and effectiveness data were collected at six sites providing directly observed treatment (DOT). Effectiveness for a 12-month cohort of new sputum positive patients was measured using cure and treatment success rates. Provider and patient costs were estimated, and analysed according to sources of financing. Cost-effectiveness is estimated from the perspective of the provider, patient and society in terms of the cost per TB case cured and cost per case successfully treated. RESULTS: Cost per case cured was significantly lower in PNP (US $354-446), and comparable between PWP (US $788-979) and public sites (US $700-1000). PPP models could significantly reduce costs to the patient by 64-100%. Relative to pure public sector provision and financing, expansion of PPPs could reduce government financing required per TB patient treated from $609-690 to $130-139 in PNP and $36-46 in PWP. CONCLUSION: There is a strong economic case for expanding PPP in TB treatment and potentially for other types of health services. Where PPPs are tailored to target groups and supported by the public sector, scaling up of effective services could occur at much lower cost than solely relying on public sector models.

Journal Article↗

Complementary and alternative medicine utilisation in NHS and private clinic settings: a United Kingdom survey of 400 infertility patients.

Some evidence suggests that complementary and alternative medicine (CAM) has found increased utilisation among patients seeking infertility treatment, although there is little information available to quantify this phenomenon. This is important information as there is marketing for CAM directed to this group and professionals need to be aware of the treatments their patients are receiving. Patients attending for infertility diagnosis and treatment often ask the physician about CAM; this paper seeks to compare the prevalence of CAM use among infertility patients in National Health Service (NHS) and private clinics. This paper provides results of a survey of couples (n = 400) divided equally between NHS and private settings. Our data suggest a high use of CAM particularly among female private patients, although patients appear sceptical of the efficacy of such treatment which is consistent with the literature.

Journal Article↗

Buying best value health care: Evolution of purchasing among Australian private health insurers.

Since 1995 Australian health insurers have been able to purchase health services pro-actively through negotiating contracts with hospitals, but little is known about their experience of purchasing. This paper examines the current status of purchasing through interviews with senior managers representing all Australian private health insurers. Many of the traditional tools used to generate competition and enhance efficiency (such as selective contracting and co-payments) have had limited use due to public and political opposition. Adoption of bundled case payment models using diagnosis related groups (DRGs) has been slow. Insurers cite multiple reasons including poor understanding of private hospital costs, unfamiliarity with DRGs, resistance from the medical profession and concerns about premature discharge. Innovation in payment models has been limited, although some insurers are considering introduction of volume-outcome purchasing and pay for performance incentives. Private health insurers also face a complex web of regulation, some of which appears to impede moves towards more efficient purchasing.

Journal Article↗

Concordance between clinicians' and patients' ratings of anxiety and depression as mediated by private self-consciousness.

This study assesses the relations between the ratings of clinicians and psychiatric inpatients on several anxiety and depression measures, as mediated by private self-consciousness. The overall concordance between clinicians' and patients' ratings is quite high, particularly on the depression measures. Levels of private self-consciousness do not appear to mediate concordance of structured behavior or symptom-based ratings of either anxiety or depression; however, there is limited support for levels of private self-consciousness mediating concordance between patients' global ratings of anxiety and clinicians' anxiety ratings.

Adult↗

The potential impact of private long-term care financing options on Medicaid: the next thirty years.

This study analyzes the potential effect on the Medicaid program of private sector financing mechanisms for long-term care. The data are from the Brookings-ICF Long-Term Care Financing Model and include projections over the next thirty years. While private financing alternatives have some modest impacts on Medicaid expenditures and the number of Medicaid long-term care recipients, the data suggest relatively little change in the need for Medicaid. There will be substantial increases in Medicaid long-term care expenditures over time, and private sector options cannot change this much.

Aged↗

The impact of public health care financing policies on private-sector hospital costs.

Two of the best-known economic models of hospital behavior are utilized to examine theoretically the issue of cross-subsidization of hospital costs between public and private-pay patients. It is shown that the existence of public/private hospital-charge differentials does not, in itself, demonstrate that public programs are subsidized by the private sector. This differential is to be expected, whether hospitals are considered to be monopolistic profit maximizers or controlled by physicians. While cost-based hospital reimbursement may be dynamically inefficient, it is shown to have certain static efficiency properties when hospitals provide services to both public and private patients.

Costs and Cost Analysis↗

The private sector and competition in health care markets.

This paper reviews the historical trends in the regulatory and competitive approaches to containment of health care costs, covering efforts in both public and private sectors. The current interest in the potential of private-sector initiatives to stimulate competition in health care insurance and provider markets is highlighted. Since neither the workings of competition in health care nor the role and impact of the private sector in stimulating such competition are well understood, the concluding section discusses important research issues surrounding these topics.

Cost Control↗

State Medicaid and private payer reimbursement for telemedicine: An overview.

Individual states in the USA were given the option of paying for telemedicine services with Medicaid (i.e. federal health-care funds administered by the state) in 1998, when the Health Care Financing Administration (HCFA) published final rules for Medicare payment for teleconsultations in health professional shortage areas (HPSAs). It was left to telemedicine practitioners in each state to negotiate the scope of the services covered with the state Medicaid office. Three reports of data gathered by 2002-03 surveys on state reimbursement policies have been reviewed, with additional information from a brief informal 2005 survey conducted by the author. In the seven years since 1998, 34 states have added coverage of telemedicine services to their Medicaid programmes, although there are wide variations in service coverage, payment policies, and geographical and other restrictions. There is less published information on private payer reimbursement. One survey performed by AMD Telemedicine (AMD) and the American Telemedicine Association (ATA) showed that over half of the 72 telemedicine programmes in 25 states delivering billable services were being reimbursed by private payers. In 1999, 43% of responding telemedicine networks saw reimbursement as a barrier to long-term sustainability, while in 2004 only 22% did so. It appears that some progress has been made in Medicaid and private payer reimbursement for telemedicine.

Delivery of Health Care↗

Extending private pension coverage in a middle-income country: the case of Brazil.

Government policies can play an important role in the development of private pensions. These policies can be divided into three groups: (1) policies that are essential to providing a favorable economic environment for pensions; (2) policies that encourage the development of private pensions, given that a favorable economic environment for them exists; and (3) policies that deal with weaknesses of private pension systems. While the policies discussed are generally applicable for middle-income countries, the economic and legal environments for pensions differ across countries. This article focuses in particular on the situation in Brazil.

Aged↗