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Report of the Northern California Conference for Guidelines on Aid-in-Dying: definitions, differences, convergences, conclusions.

In September 1996, the Stanford University Center for Biomedical Ethics convened a conference entitled "Comprehensive Care of the Terminally Ill: The Northern California Consensus Development Conference for Guidelines on Aid-in-Dying." The regionally based, multidisciplinary conference gathered people from a variety of disciplines and diverse perspectives on physician aid-in-dying. This report documents important points of convergence, disagreement, and uncertainty that emerged from the conference and provides commentary on crucial issues: the definition of terminal illness, ensuring adequate palliative care, psychiatric challenges, coping with family pressures, the doctor-patient relationship, the managed care context, the role of ethics committees, and institutional challenges. Should physician aid-in-dying become a legal practice in California, the report will provide guidance to health care organizations, health professionals, and public policy officials engaged in local or state guideline or policy development.

California↗

Overview of publicly funded managed behavioral health care.

Using MEDLINE and other Internet sources, the authors perform a systematic review of published literature. A total of 109 articles and reports are identified and reviewed that address the development, implementation, outcomes, and trends related to Managed behavioral health care (MBHC). MBHC remains a work in progress. States have implemented their MBHC programs in a number of ways, making interstate comparisons challenging. While managed behavioral health care can lower costs and increase access, ongoing concerns about MBHC include potential incentives to under-treat those with more severe conditions due to the nature of risk-based contracting, the tendency to focus on acute care, difficulties assuring quality and outcomes consistently across regions, and a potential cost-shift to other public agencies or systems. Success factors for MBHC programs appear to include stakeholder involvement in program and policy development, effective contract development and management, and rate adequacy.

Cost Savings↗

Reflections on nursing as a career choice.

AIM: The study sought to explore (1) reasons for choosing nursing as a career; (2) expectations, if any, of nursing; (3) whether those expectations had been realized; (4) how such expectations had been met or could be met. BACKGROUND: Nursing recruitment and retention are of central concern to health care. The Audit Commission have highlighted the costs of 'preventable' staff attrition and suggested that staff turnover may be minimized if staff policies reflected an understanding of the views and aspirations of staff. METHOD: A semi-structured interview survey was conducted with a quota sample of undergraduates attending one university (n = 40). Different course groups were represented. FINDINGS: Satisfaction of caring for people together with long-term desire to nurse emerged as important factors influencing career choice. Expectations included working in a caring team and having a satisfying career. Conflict experienced in the clinical setting, disappointment over the treatment of nurses and changes within the NHS and nursing were considered among the factors detracting from nursing as a career. CONCLUSION: Health care management must recognize issues of concern to nurses and develop policies which make nurses feel valued.

Altruism↗

Employment transitions for older nurses: a qualitative study.

AIM: This paper aims to explore the influences on employment related decision making in respect of nurses over 50 in the United Kingdom. It investigates the retirement and labour market relationship through the diverse experiences of older nurses and stakeholders in nursing. BACKGROUND: The ageing of the United Kingdom nursing workforce constitutes a potential challenge for the National Health Services. There is evidence of increasing efforts to address this issue by encouraging older nurses to remain in the profession, dissuading early retirement and attracting nurses who have retired to return to nursing. However, decision-making by older nurses is influenced by a wide spectrum of factors and perceived employment options. BACKGROUND: The paper is based on research commissioned by the Joseph Rowntree Foundation as part of its Transitions Over 50 programme. It derives from concern about inadequate knowledge of, and under-developed policy responses to, the ageing United Kingdom workforce and the specific implications of this age shift for the nursing labour market. The research consisted of interviews with nurses over 50 and key stakeholders in nursing in the United Kingdom. Stakeholders included employers, advisers and policy makers in nursing. METHOD: Interviews with older nurses and stakeholders in nursing were conducted over a period of 12 months. They included face-to-face and telephone semi-structured interviews with 84 nurses over 50 and 18 key stakeholders in nursing in the United Kingdom. Stakeholders included employers, advisers and policy-makers. FINDINGS: Employers, policy makers and advisers and older nurses all identified a range of influences on nurses' employment decisions including a lack of flexible hours, the stress of work, pension-related expectations and the pace of change. Some of these related to negative aspects of work that led nurses to leave ('push' factors), and others to the presence of positive factors in nursing or in pension options ('pull' factors). CONCLUSION: The study highlighted the need for increased implementation of more flexible hours of work and greater availability of part-time hours for older nurses. It revealed the salience of improved pay, adequate and flexible pensions provision, and opportunities for continued professional development to the recruitment and retention of older nurses.

Age Factors↗

Agriculture: access to technology limited.

From country to country and even regionally, the roles of women in agriculture vary, but most of their labor is in unpaid subsistence production and their contributions tend to be underestimated, according to the results of the [UN] Secretary-General's report. Depending on circumstances, they have complementary roles with men, sharing or dividing tasks in the production of crops, care of animals, and forestry management. In sub-Saharan Africa, for example, women contribute 60-80% of labor in food production for both household consumption and sale, while in Malaysia the women account for only 35% of the agricultural labor force, and in Ireland the participation rate is only 10.4%. Although women make this important amount of labor contributions to agricultural production, "development policies tend to favor export crops to earn foreign exchange and the agricultural research tends to address the improvement of production and technologies for commercial production". This results in limited access for women to technical knowledge and innovations, including irrigation, machinery, farming techniques and extension services. This is strengthened by the fact that most of the extension services target farmers who own land and can obtain credit to invest in input and technology.

Agriculture↗

Targets as a tool in health policy. Part II: Guidelines for application.

The use of health targets as a tool in health policy is receiving more attention. Beyond political will and daring, there awaits the challenge of the fruitful use of health targets. This means an adequate response to the complexity of population health in a target structure that is transparent, controllable, and adaptable in changing circumstances. In this article, we will review the health policy development cycle in relation to health target setting. First, there should be understanding of the problem, and a clear picture of the health status of the population. Then a solution can be chosen. This part is not restricted to the technical side of the solution, i.e. the target setting and action planning. It also has a political side in which responsibility is taken for the choices made. In the next step, the chosen solutions are implemented by government and stakeholders. This will be followed by a monitoring and evaluation phase, which will in turn provide us with an insight into the health status of the population. At every stage of the health policy cycle, questions which should be addressed when using health targets in health policy will be discussed.

Community Health Planning↗

Report of the NASPE policy conference on arrhythmias and the athlete.

INTRODUCTION: This consensus statement summarizes the proceedings of The Expert Consensus Conference on Arrhythmias in the Athlete of the North American Society of Pacing and Electrophysiology (NASPE) on detecting, evaluating, and treating athletes with cardiovascular disorders that predispose to cardiac arrhythmias. METHODS AND RESULTS: The participants in the open policy conference were selected by the codirectors (Drs. Estes and Olshansky) based on expertise and contributions to the literature. All participants provided a referenced summary of their presentation. The writing group used the information from all published scientific studies, clinical trials, registries, clinical experience, and expert opinion to make recommendations regarding screening, evaluation, management, eligibility for competition, and a range of other medical, social, and legal issues regarding the recreational and competitive athlete. The codirectors of the symposium synthesized the participants' reports for this and made revisions according to suggestions of all members of the writing committee. The manuscript was reviewed by four independent reviewers assigned by the NASPE Committee for the Development of Position Statements and NASPE Board of Trustees. CONCLUSION: Despite considerable advances in knowledge regarding the diagnosis, therapy, and mechanisms of arrhythmias in the athlete, much remains unknown. Continued basic, clinical, and epidemiologic research is needed. Current screening techniques to detect athletes lack sensitivity and specificity. Evaluation of standardized screening programs with tracking of long-term outcomes is needed. Officials from athletic, academic, medical, and legal institutions need to form strategic partnerships to develop policy related to assessment of risk and assumption of responsibility for athletic activities.

Arrhythmias, Cardiac↗

Educating for evidence-based practice.

Several countries have developed policy initiatives that require health care to be evidence based and health science students to study under an evidence-based curriculum as well as learn how to practice in an evidence-based way. Evidence-based nursing (EBN) is too new to have any actual research on which to base a curriculum. However, in the absence of evidence, several schools of nursing have moved or are moving forward. This article presents ideas and examples gleaned from colleagues around the world on the why's and how's of teaching EBN. Finally, this article calls for the funding and planning of an evaluation of evidence-based curricula and teaching strategies for continued development of the field.

Attitude of Health Personnel↗

Trauma system development in a theater of war: Experiences from Operation Iraqi Freedom and Operation Enduring Freedom.

BACKGROUND: Medical lessons learned from Vietnam and previous military conflicts led to the development of civilian trauma systems in the United States. Operation Iraqi Freedom represents the first protracted, large-scale, armed conflict since the advent of civilian trauma systems in which to evaluate a similar paradigm on the battlefield. METHODS: Collaborative efforts between the joint military forces of the United States initiated development of a theater trauma system in May 2004. Formal implementation of the system occurred in November 2004, the collaborative effort of the three Surgeons General of the U.S. military, the United States Army Institute of Surgical Research, and the American College of Surgeons Committee on Trauma. One trauma surgeon (Trauma System Director) and a team of six trauma nurse coordinators were deployed to theater to evaluate trauma system component issues. Demographic, mechanistic, physiologic, diagnostic, therapeutic, and outcome data were gathered for 4,700 injured patients using the Joint Theater Trauma Registry. Interview and survey methods were utilized to evaluate logistic aspects of the system. RESULTS: System implementation identified more than 30 systemic issues requiring policy development, research, education, evaluation of medical resource allocation, and alterations in clinical care. Among the issues were transfer of casualties from point of injury to the most appropriate level of care, trauma clinical practice guidelines, standard forms, prophylactic antibiotic regimens, morbidity/mortality reporting, on-line medical evacuation regulation, improved data capture for the trauma registry, and implementation of a performance improvement program. CONCLUSIONS: The implementation of a theater trauma system demonstrated numerous opportunities to improve the outcome of soldiers wounded on the battlefield.

Hospitals, Packaged↗

What is the psychiatrist's role in drugs and alcohol?

OBJECTIVE: This article describes a consensus view of the role of psychiatrists in respect of alcohol and other drug (AOD) problems, in response to the view expressed by Wodak [1]. METHOD: The data were selected on the basis of the knowledge and experience of the authors. RESULTS: Psychiatrists have made major contributions in the primary, secondary and tertiary prevention of AOD problems over many years in Australia and New Zealand. In recent years there has been an explosion of new knowledge in the AOD area and a shift from mental health to primary and public health care for these patients. Substance use disorders (SUD) are highly prevalent in all areas of psychiatric practice, requiring treatment in their own right as well as complicating the treatment of coexisting psychiatric illness. CONCLUSION: It is argued that psychiatrists have important roles in harm reduction, prevention and policy development; brief and early intervention in SUD in liaison and child psychiatry; and systematic treatment for those with dependence and other psychiatric comorbidity. A research and collaborative approach to AOD services and patients should be encouraged, rather than engaging in divisive debate over "ownership' of this area of clinical practice.

Adolescent↗

Self-regulatory codes of conduct: are they effective in controlling pharmaceutical representatives' presentations to general medical practitioners?

Self-regulatory codes of conduct are used to control the promotional practices of the pharmaceutical industry, but the effectiveness of these codes in controlling pharmaceutical representatives' presentations has not been examined. This is a matter of concern because pharmaceutical representatives have more influence than any other promotional media on prescribing practices. The authors developed a method for monitoring the oral presentations of pharmaceutical representatives when promoting products to medical practitioners. Sixteen audio-recordings, detailing 64 medicines, were obtained; 38 of the 64 products were prescription-only medicines. Information on indications and on dosage and administration was commonly provided, but information on other areas of drug knowledge, particularly product risk, was minimal. Thirteen presentations contained at least one inaccuracy when compared with Australian Approved Product Information. Presentations did not always comply with current guidelines in the Code of Conduct. The Code provides only limited standards for pharmaceutical representatives' presentations, and no active monitoring system is in place to ensure adherence to the code. There is an urgent need for policy development on the role of pharmaceutical representatives, their standards of practice, and regulation of their activities to ensure they contribute to the appropriate use of medicines.

Australia↗

To build a bridge: the use of foreign models by domestic critics of U.S. drug policy.

Domestic critics of American policy concerning illicit drugs have frequently looked abroad for evidence to bolster their agenda. Policies developed elsewhere, specifically heroin maintenance in Britain and harm reduction in Holland, have profoundly affected debate over the American approach to addiction. In each instance, the interest in foreign models was whetted by a perceived social emergency: the heroin epidemic following World War II and the HIV epidemic of the last decade.

Acquired Immunodeficiency Syndrome↗

Deinstitutionalization in context.

Unlike other policy developments, which are regular and cumulative or even circular, reforms in mental health have been characterized by a peak-trough movement. Public responses continue to be very different from professional responses to achieving the practical limits of mental health. Ironically, the lack of machinery to integrate special services into a broad national program has mobilized more creative energy in the United States than has been the case in Britain.

Community Mental Health Services↗

Rural Canadian community health and quality of life: testing a workbook to determine priorities and move to action.

BACKGROUND: Rural residents, rural community leaders, rural planners, rural health authorities and community organizations seek to understand the health, quality of life and sustainability of their communities. The aim of this article is to follow the cooperative community-based process of developing and testing a workbook to be used to assess and foster rural communities' health, quality of life and ultimately their sustainability. ISSUE: In a Social Sciences and Humanities Research Council of Canada funded, 3 phase project, entitled Determinants of Health of Rural Populations and Communities, researchers at Brandon University, University of Manitoba and Concordia University, Canada, partnered various stakeholder groups in an visionary effort to build a framework and indicators for the purpose of assisting rural communities to assess not only their health and wellbeing, but also their sustainability. CONCLUSION: In this on-going project, it is anticipated that the findings related to the health, wellbeing, quality of life and sustainability of rural communities will be integral to policy development by local, provincial and federal organizations and governments well into this century. Moreover it is expected that diverse community-based organizations will be able to use the findings to take action, particularly in an intersectoral manner, the outcome of which will be an improvement of the rural resident and community health.

Journal Article↗

Mekong malaria. II. Update of malaria, multi-drug resistance and economic development in the Mekong region of Southeast Asia.

In an expansion of the first Mekong Malaria monograph published in 1999, this second monograph updates the malaria database in the countries comprising the Mekong region of Southeast Asia. The update adds another 3 years' information to cover cumulative data from the 6 Mekong countries (Cambodia, China/Yunnan, Lao PDR, Myanmar, Thailand, Viet Nam) for the six-year period 1999-2001. The objective is to generate a more comprehensive regional perspective in what is a global epicenter of drug resistant falciparum malaria, in order to improve malaria control on a regional basis in the context of social and economic change. The further application of geographical information systems (GIS) to the analysis has underscored the overall asymmetry of disease patterns in the region, with increased emphasis on population mobility in disease spread. Of great importance is the continuing expansion of resistance of P. falciparum to antimalarial drugs in common use and the increasing employment of differing drug combinations as a result. The variation in drug policy among the 6 countries still represents a major obstacle to the institution of region-wide restrictions on drug misuse. An important step forward has been the establishment of 36 sentinel sites throughout the 6 countries, with the objective of standardizing the drug monitoring process; while not all sentinel sites are fully operational yet, the initial implementation has already given encouraging results in relation to disease monitoring. Some decreases in malaria mortality have been recorded. The disease patterns delineated by GIS are particularly instructive when focused on inter-country distribution, which is where more local collaborative effort can be made to rationalize resource utilization and policy development. Placing disease data in the context of socio-economic trends within and between countries serves to further identify the needs and the potential for placing emphasis on resource rationalization on a regional basis. Despite the difficulties, the 6-year time frame represented in this monograph gives confidence that the now well established collaboration is becoming a major factor in improving malaria control on a regional basis and hopefully redressing to a substantial degree the key problem of spread of drug resistance regionally and eventually globally.

Animals↗

Practice guidelines and professional autonomy in a universal health insurance system: the case of tissue plasminogen activator in Ontario.

Ontario's universal health insurance system has placed few constraints on the clinical and economic autonomy of medical doctors. Although fees are standardized, most physicians remain in private fee-for-service practice and thereby retain control of the mix and volume of services. Utilization review is minimal. While organized medicine has argued that health care is 'under-funded', the government is pressing for better use of extant resources through firmer management of the medical services sector. The Ontario Medical Association (OMA), the major bargaining agent for doctors in the province, has accordingly sought to protect professional autonomy by developing voluntary self-regulatory approaches that obviate the need for external controls over physician practice patterns. Part of this strategy is promulgation of practice guidelines. Tissue plasminogen activator (t-PA), a clot-lysing drug for myocardial infarction, was released in late 1987, and, at C$2950 per treatment, constituted an unforeseen add-on cost for hospitals. The OMA subsequently convened an expert panel to develop guidelines for thrombolysis in myocardial infarction. Among the unanticipated results was the conclusion that insufficient evidence had accumulated to recommend routine use of t-PA instead of streptokinase, an older drug costing C$290. The OMA panel's guidelines were approved by the OMA executive, and led the government to reject special add-on funding for hospitals purchasing t-PA. The OMA's position and government decision provoked negative reactions from the OMA's own cardiology section. Indicative of clinicians' feelings, a follow-up survey of cardiologists and internists showed that only 28% of respondents were indifferent between t-PA and streptokinase, while 64% preferred t-PA. On the other hand, 74% supported clinical policy development by the OMA, while 94% opposed direct government involvement in guideline-setting. The case of the OMA thrombolysis guidelines illustrates a strategic conundrum facing Canadian organized medicine. Professional activism in guideline-setting may in theory protect the individual practitioner's autonomy by offering a voluntary alternative to utilization management by government, and is likely to strengthen the collective influence of organized medicine. However, among the risks are alienation of practitioners who see professional guidelines and government control as two sides of the same regulatory coin, and the transmogrification of voluntary guidelines into parameters for cost control and utilization management by government or hospitals. Future initiatives will depend on how these benefits and risks are weighed.

Cost Control↗

Critical analysis on best practices in health literacy.

From a holistic perspective, health literacy is a requirement for the well-being of entire populations. It moves beyond the focus on individuals to consider the role of organizations and systems. This perspective offers a context for discussing best practices in health literacy, and implications for research and policy development. This paper offers an overview of the best practices that were presented at the Second Canadian Conference on Literacy and Health. It discusses clear writing in some detail because it was emphasized at the conference. It also considers practices that were addressed less emphatically, such as oral communication between patients and health care professionals, training for health care professionals, non-written means of communication (such as video), and building capacity through action-research. The paper critiques some practices. It also notes the lack of research on the links between health literacy and oral understanding, on the impact of verbal and non-written interventions, and on the effectiveness of these practices on the health outcomes of the population. It briefly discusses policy issues and suggests some future directions.

Benchmarking↗

Health departments' implementation of public health's core functions: an assessment of health impacts.

OBJECTIVES: The purpose of this article was to investigate the relationship between state health agencies' adherence to the recommendations of the United State's Institute of Medicine's (IOM) report, "The Future of Public Health", and changes in their populations' health. STUDY DESIGN: Data were abstracted from agencies' plans, budgets, annual reports, etc. spanning a 5-year period. A comprehensive change in population health measure over the same period was drawn from the UnitedHealth Group's annual survey. METHODS: Configurations, based on public health core functions, were established using linear regression and qualitative comparative analysis. The dependent variable was a holistic measure of change in a state population's health status. RESULTS: State agencies that most completely adopted a public health model emphasizing assessment, assurance and policy development also experienced significant improvements in their population health measures. CONCLUSIONS: State agencies that more completely adopted the IOM's public health core functions had a concomitant improvement in their populations' health statuses. Further research to explore if there is a causal link between adoption of the core functions and positive health impacts is warranted.

Government Agencies↗