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PubMed1996

Outcomes management: an interdisciplinary search for best practice.

Rising U.S. health-care costs have resulted in mandates to reform the health system. Payors are closely scrutinizing care delivery and have empowered themselves as gatekeepers for consumer health-care access. In the late 1980s, outcomes management emerged as an interdisciplinary process advocating the measurement of health outcomes among populations undergoing medical care. Outcomes management provides a mechanism to foster development of patient-driven health services aimed to impact clinical quality through intermediate and long-term outcome analysis. Outcomes measurement facilitates ongoing enhancement of interdisciplinary health-care delivery, enabling determination of "best" practice and identification of opportunities for practice improvement. The advanced practice nurse's unique educational preparation provides a framework for development of the prerequisite leadership qualities necessary to cultivate an outcomes management program.

Case Management↗
PubMed1995

The impact of Medicaid managed care on the public health system in Arizona: case study.

This article examines the impact of a statewide Medicaid managed care program, the Arizona Health Care Cost Containment System (AHCCCS), on the local public health system in Arizona. Based on interviews with current and former state and local public health officials, the authors describe public health concerns with capitated health care delivery systems that rely on gatekeeper systems to control utilization. The authors identified difficulties in gauging the extent of the problem, since neither public health nor managed care systems collect data on use of public health clinics by AHCCCS beneficiaries. Relationships between public health officials and managed care officials are characterized by tensions resulting from differing outlooks about access, eligibility, and the need for preventive health services. The report concludes with recommendations developed by the Association of State and Territorial Health Officials (ASTHO) Primary Care Committee on roles for state health agencies in ensuring development of appropriate managed care delivery systems for vulnerable populations.

Arizona↗
PubMed2003

The unilateral DNR order--one hospital's experience.

Hospital or institutional policies that guide the activity of nurses in the care of their patients may, at times, be controversial. Nursing staffs often act as gatekeepers of patient care activities and the implementers of institutional policy. When nurses raise questions as to the appropriateness of a given policy statement, the institution should take serious notice and, perhaps, even study the policy outcomes that relate to the concerns expressed by the nursing staff. This article introduces a policy that originally prompted serious concerns by the nursing staff at one institution. The nursing staff voiced their concerns regarding a revision in the DNR policy that would allow physicians to write unilateral do-not-resuscitate (DNR) orders. Because of this, a review of this policy took place and the results were used to dispel unfounded concerns and also to improve the use of the policy. This article may help nursing administrators to understand better the importance of policy-related studies and it may also encourage nurses to question policy statements and guidelines that may present some concerns. Enhanced patient care will ultimately result by such teamwork and scholarly activity.

Academic Medical Centers↗
PubMedDate not supplied

Recovery issues in cancer survivorship: a new challenge for supportive care.

The growing population of cancer survivors represents a clear challenge to clinicians and researchers to look beyond the search for a cure and to address the multifaceted needs of those living with and beyond a cancer diagnosis. Common sequelae that disrupt the psychosocial aspects of life for adult cancer survivors after primary treatment include: fatigue; cognitive changes; body image; sexual health and functioning; infertility; fear of recurrence; PTSD and stress syndromes; family/caregiver distress; socioeconomic issues; and distress, anxiety, and depression. Psychosocial interventions, particularly group-based interventions and physical activity programs, have shown great promise in improving these outcomes. Future research will identify even better targeted, more efficacious, and more cost effective programs and disseminate them into cancer care settings. Healthcare providers must realize that they serve as vital gatekeepers to services that will help optimize cancer survivors' psychosocial as well as physical outcomes. Addressing these issues in the post-treatment period represents the new challenge to supportive care.

Adaptation, Psychological↗
PubMed2005

The Th1/Th2 paradigm in ocular allergy.

PURPOSE OF REVIEW: The paradigm that diseases are either Th1 mediated or Th2 mediated has recently been challenged in a number of classical ocular diseases. The objective of this article is to highlight the importance of understanding the exact mechanisms of Th1 and Th2 cells in the pathology of ocular allergy. RECENT FINDINGS: Current research of Th1 and Th2 cytokines in an animal model of ocular allergy demonstrates the intricate complex regulation by both subsets of cytokines of the disease process. Th2 prone BALB/c wild type mice sensitized and topically challenged with short ragweed for seven consecutive days (multi-hit) developed a sustained, chronic conjunctival inflammation. Significantly, IFN-gamma knockout mice in the multi-hit antigen challenge model had a reduced conjunctival cellular infiltrate. Evaluation of adhesion molecules that actively regulate cellular infiltration into the conjunctiva revealed a lack of vascular cell adhesion molecule-1 in multi-hit antigen challenged IFN-gamma knockout mice. SUMMARY: Recent ocular allergy studies question the Th1/Th2 paradigm. These studies encourage further understanding of the intricate interactions of Th1 and Th2 cytokines in ocular inflammatory disease. The following components of Th1 and Th2 cells in the development of chronic inflammation associated with allergic conjunctivitis will be discussed: T helper subsets Th1 and Th2 in ocular inflammation, activation of T cells in the lymph node, and the role of IFN-gamma as the endothelium gatekeeper in the pathology of Th2-mediated allergic conjunctivitis.

Animals↗
PubMed2005

Help-seeking for child psychopathology: pathways to informal and professional services in the Netherlands.

OBJECTIVE: To devise and test a model describing the process of help-seeking for child psychopathology in professional and informal service settings. METHOD: Using structural equation modeling, associations between several help-seeking stages, and the influence of child, family, and context characteristics on these stages were investigated in 246 Dutch children (4-11 years old) between April 2000 and July 2002. Children were selected for having emotional or behavioral problems from a representative general practice sample; 68% of the selected children participated. RESULTS: School personnel played an important role in the process of help-seeking for child psychopathology, in both detecting service need and the provision of and the referral for help. Although Dutch general practitioners are supposed to be gatekeepers of mental health care, their role in help-seeking for child psychopathology was limited. Various family characteristics were shown to influence service need and informal or professional help-seeking. The influence of child characteristics on the help-seeking process was limited. CONCLUSIONS: Educating parents about child psychopathology and the availability and accessibility of care, improving general practitioners' skills in detecting child psychopathology, and direct contact of mental health professionals with general practitioners and schools may enhance access to care for children in need.

Affective Symptoms↗
PubMed2006

Teachers' beliefs about mental health needs in inner city elementary schools.

OBJECTIVE: To survey teachers' beliefs about mental health service needs in inner city elementary schools. METHOD: A total of 119 teachers from six elementary schools in a major city in the midwestern United States were surveyed to assess their beliefs about the major mental health problems facing their schools, the major barriers to surmounting those problems, their preferences for mental health topics for in-service education, and their education, experience, knowledge, attitudes, and self-efficacy pertaining to mental health issues. RESULTS: Disruptive behavior was endorsed by approximately 50% of teachers as the largest mental health problem facing their schools, and lack of information/training was endorsed as the greatest barrier to surmounting mental health problems. The highest-rated topics for in-service education were disruptive behavior disorders and implementing behavior plans. Although most teachers had taught students with mental health problems, most had had little education in mental health and little consultation with mental health professionals. Correspondingly, teachers' knowledge about mental health issues was limited, and they did not feel confident about their ability to manage mental health problems in their classrooms. CONCLUSIONS: Teachers would benefit from education, training, and consultation from mental health professionals if they serve as effective gatekeepers to mental health services.

Adult↗
PubMed2004

The influence of physicians' practice management strategies and financial arrangements on quality of care among patients with diabetes.

CONTEXT: Health care organizations use many strategies to influence physician behavior and the care delivered, but the effect of such strategies on quality is not known. OBJECTIVE: We sought to assess the influence of practice management strategies and financial arrangements on the quality of diabetes care. DESIGN: This was a retrospective cohort study including medical record reviews and a physician survey. PARTICIPANTS: Patients with diabetes mellitus (n=652) enrolled in 3 health plans located in Minnesota and 399 physicians in 135 practices who cared for them participated in this study. MAIN OUTCOME MEASURE: Our main outcome measures was a quality score indicating receipt of care in accordance with 6 accepted quality indicators. RESULTS: The mean quality score was 2.4 (SD 1.2) on a 6-point scale. Only a small proportion of the variation in quality was attributed to characteristics of physicians' practices (5%). Quality scores tended to be higher for patients whose physicians received quality performance reports or utilization profiles from more than 1 source (P=0.08), routinely enrolled diabetic patients in disease-management programs (P=0.06), or received diabetes-specific reports (P=0.06). Quality scores were lower for patients whose physicians were paid according to fee-for-service compared with salary (P=0.04) and served as gatekeepers for >50% of their patients (P=0.06). However, these findings were all of borderline statistical significance, and the absolute differences in quality were small. CONCLUSIONS: Current practice management strategies and financial arrangements have a limited impact on the quality of care for patients with diabetes. These findings suggest that other strategies may be necessary for health care organizations to improve care for patients with diabetes.

Adult↗
PubMed2006

The roles of kisspeptins and G protein-coupled receptor-54 in pubertal development.

PURPOSE OF REVIEW: This review summarizes the experimental data demonstrating the fundamental role of kisspeptins and their G protein-coupled receptor GPR54 in the control of reproduction, with special emphasis on their function at puberty. RECENT FINDINGS: Kisspeptins, products of the KiSS-1 gene, were originally identified as metastasis suppressor peptides with the ability to bind G protein-coupled receptor GPR54. In late 2003, loss-of-function mutations of the GPR54 gene were found in patients suffering from hypogonadotropic hypogonadism. This finding kicked off the analysis of the role of the KiSS-1/GPR54 system in the control of reproduction. Kisspeptins are very potent elicitors of gonadotropin secretion, primarily through stimulation of gonadotropin-releasing hormone release. Enhanced expression of KiSS-1 and GPR54 genes, as well as increased GPR54 signaling, are detected at the hypothalamus during pubertal development, and activation of GPR54 by administration of kisspeptin is sufficient to induce precocious activation of the gonadotropic axis in immature rodents and monkeys. Hypothalamic KiSS-1 also functions as an essential integrator for peripheral inputs, including gonadal steroids and nutritional signals, controlling gonadotropin-releasing hormone and gonadotropin secretion. SUMMARY: Kisspeptins and their putative receptor, GPR54, have recently emerged as indispensable factors for pubertal development, with a key role as gatekeepers of gonadotropin-releasing hormone release neurons and, hence, of reproductive function.

Animals↗
PubMed2004

The tip of the iceberg for child abuse: the critical roles of the pediatric trauma service and its registry.

BACKGROUND: The incidence of child abuse is approximately 10% of all children presenting to an emergency department (ED), with a mortality rate less than 1%. By contrast, the characteristics of the subset of abused children presenting to a pediatric trauma service (PTS) is not well defined. METHODS: This study was a retrospective evaluation of prospectively collected information from an urban Level I pediatric trauma registry from 1990 to 2002 (n = 11,919). Child abuse cases and their perpetrators were identified by E-codes. Patterns of injuries were examined by integer International Classification of Diseases, Ninth Revision codes, and diagnostic model was evaluated by discrimination and goodness-of-fit. RESULTS: A total of 171 cases of child abuse (1.4%) were identified, and the majority were boys (59%, p > 0.05 vs. nonabuse cases). The median age of the abused cohort was younger than 1 year old, and the number of abuse cases did not differ over time (mean, 11 per year.) Abused children present with a higher median Injury Severity Score (10 vs. 4, p < 0.01), more severe injuries of the head and integument, longer hospital lengths of stay (4 vs. 1 day, p < 0.01), and a higher mortality rate (12% vs. 2%, p < 0.01). The following variables emerged with significant association to abuse: fracture of base or vault of skull, contusion of eye, rib fracture, intracranial bleeding, multiple burns, and age. A new Diagnostic Index for Physical Child Abuse was created. CONCLUSION: Significant characteristics of the abused children in this pediatric trauma service include higher Injury Severity Score (especially in the head and integument), requirement for longer lengths of stay, and a nearly 10-times higher risk of death compared with the ED population. The Diagnostic Index for Physical Child Abuse is proposed as a new tool to assist in the identification of child abuse among pediatric trauma patients. An epidemiologic triangle for child abuse is described, with different prevalence and severity of child abuse seen at different levels of our health care system, starting with primary care providers, followed by the ED, the PTS, and ultimately the medical examiners. The number of cases decreases from the bottom to the top of the health care system, but the mortality rate increases as abuse escalates through the triangle. This establishes the PTS as possibly the final gatekeeper before an abused case becomes a fatality. These data emphasize the need for rigorous registry evaluation and subsequent evidence-based prevention initiatives.

Baltimore↗
PubMed2003

Differential diagnosis and management of fatigue in multiple sclerosis: considerations for the nurse.

Fatigue is one of the most disabling aspects of multiple sclerosis (MS), affecting an estimated 70%-90% of patients. Yet, despite its prevalence, it is also one of the most difficult MS symptoms to accurately diagnose and effectively treat. This is because of numerous factors, including the subjective and nonspecific nature of fatigue; its variable manifestations; its similarity to psychological, motor, cognitive, respiratory, and non-MS-related disturbances and conditions; and a lack of understanding of its precise etiology. In contrast to fatigue experienced by people without MS, MS fatigue is characterized by its persistence and sensitivity to core and ambient temperatures. Differential diagnosis of MS fatigue is largely dependent on delineating chronic versus acute onset and determining whether fatigue is a symptom in and of itself (primary MS fatigue) or an aspect of an MS-related or non-MS-related etiology (secondary MS fatigue). Once the presence of fatigue is established, a through medical history, physical examination, and fatigue assessments can guide effective management, which includes education, self-care strategies, and pharmacological treatment. As patient advocates and gatekeepers, MS nurses are in an optimal position to establish and evaluate fatigue as a symptom in and of itself and effectively guide this process.

Acute Disease↗
PubMed2002

Mitochondria: regulators of cell death and survival.

The past 5 years has seen an intense surge in research devoted toward understanding the critical role of mitochondria in the regulation of cell death. Apoptosis can be initiated by a wide array of stimuli, inducing multiple signaling pathways that, for the most part, converge at the mitochondrion. Although classically considered the powerhouses of the cell, it is now understood that mitochondria are also "gatekeepers" that ultimately determine the fate of the cell. The mitochondrial decision as to whether a cell lives or dies is complex, involving protein-protein interactions, ionic changes, reactive oxygen species, and other mechanisms that require further elucidation. Once the death process is initiated, mitochondria undergo conformational changes, resulting in the release of cytochrome c (cyt c), caspases, endonucleases, and other factors leading to the onset and execution of apoptosis. The present review attempts to outline the complex milieu of events regulating the mitochondrial commitment to and processes involved in the implementation of the executioner phase of apoptotic cell death.

Animals↗
PubMed1999

Apc1638T: a mouse model delineating critical domains of the adenomatous polyposis coli protein involved in tumorigenesis and development.

The adenomatous polyposis coli (APC) gene is considered as the true gatekeeper of colonic epithelial proliferation: It is mutated in the majority of colorectal tumors, and mutations occur at early stages of tumor development in mouse and man. These mutant proteins lack most of the seven 20-amino-acid repeats and all SAMP motifs that have been associated with down-regulation of intracellular beta-catenin levels. In addition, they lack the carboxy-terminal domains that bind to DLG, EB1, and microtubulin. APC also appears to be essential in development because homozygosity for mouse Apc mutations invariably results in early embryonic lethality. Here, we describe the generation of a mouse model carrying a targeted mutation at codon 1638 of the mouse Apc gene, Apc1638T, resulting in a truncated Apc protein encompassing three of the seven 20 amino acid repeats and one SAMP motif, but missing all of the carboxy-terminal domains thought to be associated with tumorigenesis. Surprisingly, homozygosity for the Apc1638T mutation is compatible with postnatal life. However, homozygous mutant animals are characterized by growth retardation, a reduced postnatal viability on the B6 genetic background, the absence of preputial glands, and the formation of nipple-associated cysts. Most importantly, Apc1638T/1638T animals that survive to adulthood are tumor free. Although the full complement of Apc1638T is sufficient for proper beta-catenin signaling, dosage reductions of the truncated protein result in increasingly severe defects in beta-catenin regulation. The SAMP motif retained in Apc1638T also appears to be important for this function as shown by analysis of the Apc1572T protein in which its targeted deletion results in a further reduction in the ability of properly controlling beta-catenin/Tcf signaling. These results indicate that the association with DLG, EB1, and microtubulin is less critical for the maintenance of homeostasis by APC than has been suggested previously, and that proper beta-catenin regulation by APC appears to be required for normal embryonic development and tumor suppression.

Adenomatous Polyposis Coli Protein↗
PubMed2005

A mechanism of ubiquitin-independent proteasomal degradation of the tumor suppressors p53 and p73.

Protein degradation is an essential and highly regulated process. The proteasomal degradation of the tumor suppressors p53 and p73 is regulated by both polyubiquitination and by an ubiquitin-independent process. Here, we show that this ubiquitin-independent process is mediated by the 20S proteasomes and is regulated by NQO1. NQO1 physically interacts with p53 and p73 in an NADH-dependent manner and protects them from 20S proteasomal degradation. Remarkably, the vast majority of NQO1 in cells is found in physical association with the 20S proteasomes, suggesting that NQO1 functions as a gatekeeper of the 20S proteasomes. We further show that this pathway plays a role in p53 accumulation in response to ionizing radiation. Our findings provide the first evidence for in vivo degradation of p53 and p73 by the 20S proteasomes and its regulation by NQO1 and NADH level.

Animals↗
PubMed1998

Managerialism and the British GP: the GP as manager and as managed.

The focus of the paper is on the relationship between General Practitioners (GPs) and central government. This relationship dates from the introduction of national health insurance in the UK. From the outset it had an impact on GPs' medical role, their professional status and income. The structure created in 1911 meant that GPs operated as franchisees and, notwithstanding Labour's policy objective of creating a salaried service, this role continued, effectively unchanged, after the creation of the National Health Service (NHS) in 1948. General practice was also the poor relation in contrast to hospital medicine, a feature intensified by the priorities of the NHS. These forces meant that GPs had a dual role: that of clinician and gatekeeper to specialist hospital services, a role in which they exercised substantial clinical freedom: and running a small business, a feature which was exaggerated by the absence of grant aid to improve premises prior to the Family Doctor Charter of 1965. This structural relationship has been progressively transformed by changes in the 1980s and 1990s. On the one hand the emphasis on cost control has seen central government attempting to combine a financial with a clinical gate-keeping keeping role. The crucial change in this respect is the creation of GP fundholding which, in turn, could be seen to have implications for the subordinate status of GPs within the medical profession. However, this has been combined with trends to greater measures of control over GPs. Of central importance in this respect were the changes introduced by the 1990 GP contract. The contract involved an attempt to substantially reduce clinical autonomy by building in much more detailed contractual duties with respect, for example, to health promotion activities. This was combined with the use of financial incentives to reach, for example, immunization targets. Control over clinical autonomy has also involved constraints over prescribing and the shift from Family Practitioner Committees to Family Health Service Authorities. The rationale for this shift is the move from an administrative to a managerial body, acting as the agent of central government in enforcing the contract and imposing financial norms. GPs are thus to be made managerially accountable. The paper analyses the place of general practitioners in central government's approach to health strategy and examines the tensions generated by the combination of conferring new powers on GPs and increasing controls over them. These tensions are related to current disputes over out-of-hours working and attempts by GPs to redefine a "core of service" approach to their job. The ambiguities of reliance on professionals combined with the desire to exert greater controls is traced in the recent policy statement by the Secretary of State, Primary Care: The Future (1996). The paper thus aims to contribute to the critical discussion of the impact of central government managerialist initiative on key professional groups in the welfare state.

Community Health Planning↗
PubMed1984

Doctor-patient communication: a social and micro-political performance.

In the United States the medical relationship is asymmetrical. Doctors not only control medical knowledge, they also have an institutionally based authority which allows them to act as gatekeepers, providing options to some while denying them to others. This study, conducted in a model family practice clinic of a teaching hospital, examines how decisions to do, or not to do, Pap smears are negotiated as residents and a potentially high-risk group of patients communicate. Decision-making occurs in layered phases--opening, medical history, physical examination, and closing. Each phase expresses the doctor's control and the patient's trust. Doctors initiate phases, develop topics and make key choices. They decide when patients undress--a choice which shapes the later Pap smear decision. Decisions to undress patients and to perform Pap smears or decisions not to undress patients and not to perform Pap smears produce no conflict. When there is a conflict, avoidance strategies--bowing to higher-level specialists, selling and unselling, and letting silence speak--are used negotiating devices. The doctor's choice and the patient's agreement produce a specific and a more general outcome--managing the presenting complaint and providing medically adequate health care, respectively. Although interactionally accomplished, these outcomes are institutionally constrained, and, thus are both a social and a micro-political performance.

Female↗
PubMed1999

The commodification of international migration: findings from Thailand.

"The organisation of international contract-labour migration within Asia has been increasingly dominated by commercial agencies acting as intermediaries between workers and foreign employers. The principles underpinning the gatekeeping role of such agencies in the East Asian migration system are examined. A consideration of the international labour recruitment system in Thailand is based on survey work among agents, community leaders and recently returned migrants."

Asia↗
PubMed2005

Immunoglobulin levels and phagocytes in the cervical mucus plug at term of pregnancy.

BACKGROUND: To characterize the potential for adaptive immune protection in cervical mucus plugs with respect to immunoglobulin isotypes and effector cells (phagocytes). METHODS: Thirty-one cervical mucus plugs were collected from healthy women in labor at term. The cervical mucus plugs were allocated either to analysis of immunoglobulins by enzyme-linked immunosorbent assay (ELISA), gel chromatography and Western blotting (n = 20) or to microscopical, including immunocytochemical, analyses. The levels of immunoglobulin in the plugs were compared to the levels in 10 samples of ovulatory cervical mucus from nonpregnant women. RESULTS: In the cervical mucus plugs, levels of immunoglobulin G (IgG) [median 3270 microg/mL (100-14 500)] and IgA [540 (22-2820)], but not IgM [30.5 (1.0-160)], were significantly elevated compared to cervical mucus from nonpregnant women (p < 0.02 for IgG and IgA). The IgG : IgA ratio in the plugs was also elevated (p < 0.02). The proportion of secretory immunoglobulin A (SIgA) relative to total IgA in the plugs ranged from 16 to 65% (n = 5). IgA and IgG were largely intact. Microscopically, the vagina-proximal part of the cervical mucus plugs contained bacteria and was rich in cells, mainly phagocytes. Conversely, the uterine part contained few cells. CONCLUSION: The high immunoglobulin levels in combination with the presence of phagocytes suggest a potential for adaptive immune defense in the cervical mucus plug, which, together with innate immune factors, may act as an immunological gatekeeper protecting the fetomaternal unit against infection from the vagina.

Blotting, Western↗