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PubMedDate not supplied

Variation in average costs among federally sponsored state-organized cancer detection programs: economies of scale?

BACKGROUND: Societal cost-effectiveness analysis and its variants help decision makers achieve an efficient allocation of resources across the set of all possible health interventions. Sometimes, however, decision makers are focused instead on the efficient allocation of resources within a particular intervention program that has already been implemented. This is especially true when the intervention is being delivered at several different sites. An analysis of average cost across program sites may help program officials to maximize the health benefits that can be achieved with limited resources. In this article, the authors present such an analysis, with special attention paid to the possible existence and implications of economies of scale. METHODS: Focusing on federally sponsored, state-organized cancer detection programs, the authors modeled 19 state programs as productive processes and examined their average costs over a 2- to 5-year period of operation. They considered 3 alternative definitions of output: women served, screens performed, and conditions detected. Average federal costs and average total costs were estimated for each grant period. Multivariate regression analysis was used to help explain the variation in average costs. RESULTS: The average cost estimates were distributed in a skewed pattern with the majority of observations falling close to the median and substantially below the mean. For all measures considered, average cost decreased as output expanded. This inverse relationship between average cost and output level persisted even after controlling for the effects of other predictors, suggesting the possible existence of economies of scale. DISCUSSION: The potential existence of economies of scale calls into question the assumption of a constant average cost frequently made in economic analyses of proposed public health programs. It also implies that a) differences in output level should be taken into account when comparing operating efficiency across program sites; b) conclusions from societal cost-effectiveness analyses may depend on the level of output at which the programs are evaluated; c) cost projections could be inaccurate if they do not take into account the decrease in average cost that occurs as output expands; and d) gains might be possible if similar programs with limited output potential are integrated, perhaps through cost sharing.

Breast Neoplasms↗

PubMed2000

Preventive health care, 2000 update: prevention of child maltreatment.

OBJECTIVES: To update the 1993 report from the Canadian Task Force on the Periodic Health Examination (now the Canadian Task Force on Preventive Health Care) by reviewing the evidence for the effectiveness of interventions aimed at preventing child maltreatment described in the scientific literature over the past 6 years. OPTIONS: Screening: a variety of techniques including assessment of risk indicators. PREVENTION: programs including home visitation; comprehensive health care programs; parent education and support, combined services and programs aimed specifically at preventing sexual abuse. OUTCOMES: Occurrence of one or more of the subcategories of physical abuse, sexual abuse, neglect and emotional abuse in childhood. EVIDENCE: MEDLINE, PSYCINFO, ERIC and several other databases were searched, experts were consulted, and published recommendations were reviewed. Original research articles and overviews that examined screening for or prevention of child maltreatment were included in the update. No meta-analysis was performed because the range of manoeuvres precluded comparability. BENEFITS, HARMS AND COSTS: Because of the high false-positive rates of screening tests for child maltreatment and the potential for mislabelling people as potential child abusers, the possible harms associated with these screening manoeuvres outweigh the benefits. Two randomized controlled trials showed a reduction in the incidence of childhood maltreatment or outcomes related to physical abuse and neglect among first-time disadvantaged mothers and their infants who received a program of home visitation by nurses in the perinatal period extending through infancy. It is expected that a reduction in incidence of child maltreatment and other outcomes will lead to substantial government savings. Evidence remains inconclusive on the effectiveness of a comprehensive health care program, a parent education and support program, or a combination of services in preventing child maltreatment. Education programs designed to teach children prevention strategies to avoid sexual abuse show increased knowledge and skills but not necessarily reduced abuse. VALUES: The systematic review and critical appraisal of the evidence were conducted according to the evidence-based methodology of the Canadian Task Force on Preventive Health Care. RECOMMENDATIONS: There is further evidence of fair quality to exclude screening procedures aimed at identifying individuals at risk of experiencing or committing child maltreatment (grade D recommendation). There is good evidence to continue recommending a program of home visitation for disadvantaged families during the perinatal period extending through infancy to prevent child abuse and neglect (grade A recommendation). The target group for this program is first-time mothers with one or more of the following characteristics: age less than 19 years, single parent status and low socioeconomic status. The strongest evidence is for an intensive program of home visitation delivered by nurses beginning prenatally and extending until the child's second birthday. There is insufficient evidence to recommend a comprehensive health care program (grade C recommendation), a parent education and support program (grade C recommendation) or a combination of home-based services (grade C recommendation) as a strategy for preventing child maltreatment, but these interventions may be recommended for other reasons. There is insufficient evidence to recommend education programs for the prevention of sexual abuse (grade C recommendation); whether such programs reduce the incidence of sexual abuse has not been established. VALIDATION: The members of the Canadian Task Force on Preventive Health Care reviewed the findings of this analysis through an iterative process. The task force sent the final review and recommendations to selected external expert reviewers, and their feedback was incorporated. SPONSORS: The Canadian Task Force on Preventive Health Care is funded through a partnership between the Provincial and Territorial Ministries of Health and Health Canada.

Adolescent↗

PubMed1997

Contrast of survey results between state and a cohort of nonstate mycobacteriology laboratories: changes in laboratory practices.

Based on the recommendations of a 1992 conference on tuberculosis, the Centers for Disease Control and Prevention (CDC) established programs for upgrading mycobacteriology laboratories by providing them with monies and focused training. In 1991, state public health laboratories were surveyed to determine the methods they were using for primary Mycobacterium tuberculosis testing and their turnaround times for reporting testing results. A similar survey of nonstate laboratories participating in the National Laboratory Training Network-sponsored, M. tuberculosis-focused training programs was conducted from May 1992 to June 1993. In 1994, follow-up surveys of both the state- and nonstate-laboratory cohorts were conducted with the questionnaire from the initial survey plus additional questions that asked about interventions and changes occurring in the laboratory since the original survey. Although both cohorts showed increases in the percentages of laboratories meeting the recommended turnaround times for reporting M. tuberculosis testing results and using the recommended rapid methods for testing, generally, the increases made by the state laboratories were greater. By June 1994, all state laboratories were using a rapid method for M. tuberculosis isolate identification compared with 88% of the nonstate laboratories. The percentage of laboratories identifying isolates within the recommended 21 days also increased more in the group of state laboratories than in the group of nonstate laboratories (state laboratories, 22 to 73%; nonstate laboratories, 55 to 59%). Responses from the follow-up survey showed large differences in the percentages of laboratories that received CDC funding (state laboratories, 100%; nonstate laboratories, 6%) and participated in M. tuberculosis training (state laboratories, 98%; nonstate laboratories, 45%). These results indicate that adequate funding and focused training are critical in maintaining state-of-the-art mycobacteriology laboratories.

Bacterial Typing Techniques↗

PubMed2000

The evolution of external quality evaluation: observations from the Joint Commission on Accreditation of Healthcare Organizations.

The Joint Commission on Accreditation of Healthcare Organizations, the oldest health care accrediting body in the world, currently accredits almost 20000 organizations in the USA. Although continuing to be professionally-sponsored, accreditation's rapid growth in recent years has been driven by the external users of accreditation--government, purchasers, and public--rather than by the original users, the professionals themselves. This experience in the USA suggests that over time successful external quality evaluation mechanisms throughout the world will involve representatives of the public, purchasers, and government in establishing standards and setting policies. Without this involvement, these stakeholders are unlikely to find the mechanisms credible in addressing their needs, and will seek alternatives--adding cost and duplication to the external quality evaluation system. Successful mechanisms are also likely to provide more detailed information about an organization's performance to the public, purchasers, and the government, while creating evaluation processes that provide for innovation and support improvement in efficiency, as well as quality, through incorporation of aspects of the Baldrige and European Foundation for Quality Management approaches to organizational excellence. Finally, successful evaluation mechanisms are likely to create a special focus on the safety of care, incorporating aspects of the International Organization for Standardization's ISO 9000 approach to quality management. While the specific nature, priority, and timing of these changes will differ from country to country, they are likely to influence the evolution of external quality evaluation throughout the world. External evaluation of health care organizations' quality holds great promise, but its long-term success depends on responding to all those who will want to depend on it.

Diffusion of Innovation↗

PubMed1999

Effective MCH epidemiology in state health agencies: lessons from an evaluation of the Maternal and Child Health Epidemiology Program (MCHEP).

OBJECTIVES: The Maternal and Child Health Epidemiology Program (MCHEP), jointly sponsored by the Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration (HRSA), was evaluated in 1996-1997. As part of this evaluation, an effort was undertaken to identify components of effective MCH epidemiology, to examine their prevalence across participating states, and to assess differences with respect to these components between MCHEP and non-MCHEP states. METHODS: A case-study evaluation was undertaken in which nine states (five MCHEP and four non-MCHEP) rated themselves on a benchmark questionnaire and participated in interviews conducted during site visits. At the completion of the evaluation, 16 components of effective MCH epidemiology in state health agencies were identified. The nine states were rated by the evaluation team on each component. Ratings across all states and between MCHEP and non-MCHEP states were compared. RESULTS: There was a great deal of variability among the nine states with respect to the presence of the components of effective MCH epidemiology. Components on which the states appeared weakest overall were the presence of adequately trained personnel, the presence of adequate management information systems to support MCH programs, and whether the state health agency's epidemiologic unit understands the MCH planning cycle. States with an MCHEP assignee had a higher overall mean score than non-MCHEP states across all components. There were seven components on which the two groups of states differed. These include whether the MCH director is empowered in the state health agency, whether the state health agency has identified internal epidemiologic capacity building as a priority, and whether analytic leadership is available for MCH epidemiologic activities. CONCLUSIONS: Building and maintaining MCH epidemiologic capacity in state health agencies requires attention to a variety of factors. While the presence of an MCH epidemiologist is important, this is only one of many components that must be considered as both the federal and state governments seek to promote and institutionalize effective MCH epidemiology in state health agencies.

Benchmarking↗

PubMed2004

Neuropsychotherapeutics in the UK: what has been the impact of NICE on prescribing?

The UK National Institute for Clinical Excellence (NICE) was set up in 1999 to advise the National Health Service (NHS) on the use of new technologies largely, but not exclusively, on the basis of their clinical and cost effectiveness. There have been problems with this, as with any developing system, most of which have arisen from issues not directly under the control of NICE. Despite this, NICE has already achieved a pivotal role in determining the uptake of new therapies into the NHS. In the area of neuropsychiatric therapies, NICE has examined a number of topics and has generally facilitated the increased use of the agents examined, approving the use, within limitations, of such drugs as riluzole, atypical antipsychotics and cholinesterase inhibitors. Although the use of some of these therapies had been growing, it had previously been restricted by funding in the NHS. As a result of NICE guidance, these funding restrictions have generally been lifted. NICE has rejected one area of neurological therapy so far--that of interferon-beta products and glatiramer acetate for multiple sclerosis--on the grounds of clinical uncertainty about long-term benefits and poor cost effectiveness. However, the UK Government has created a novel risk-sharing scheme in collaboration with the sponsoring companies to make these drugs available at a level of cost effectiveness acceptable to the NHS. The feasibility of this scheme is as yet unclear. This might be seen as either a triumph for NICE or as an undermining of it for political ends. One interesting aspect that is more prominent in neuropsychiatric disorders than in other areas of NICE activity has been the power of patient advocacy in encouraging acceptance of therapies where the evidence base was weak or the incremental cost-effectiveness ratio was unfavourable. The principles behind the activities of NICE attract wide support within the NHS, but the details of its decisions have often not been popular within NHS management who have to deliver them. Some of this relates more to the context and political environment within which NICE operates than to a failing within NICE itself. NICE will continue to become increasingly important in determining the use of new drugs within the UK NHS.

Antipsychotic Agents↗

PubMed1997

Dietary analysis of meals served in the breakfast and lunch programs of Puerto Rican schools.

BACKGROUND: Nutritional analysis of meals in the Federally-sponsored Breakfast and Lunch Programs in Stateside Schools has recently been completed. However due to ethnic and cultural differences, the findings may not be directly applicable to similar nutrition programs in Puerto Rico. It is our aim to carry out an analysis of meals served in Federal programs in Puerto Rico and to compare results to the stateside study. METHODS: Twenty eight different breakfast meals and 96 different lunch meals being cycled in elementary, middle and secondary schools throughout the entire island of Puerto Rico were analyzed for content using the Minnesota Nutrition Data System 32 and compared with: 1) compliance to meal pattern requirements of federal programs, 2) dietary guidelines for Americans (DG) and 3) recommended dietary allowances (RDA's). RESULTS: Breakfasts and lunches served in Puerto Rican Schools satisfy federal meal pattern requirements however most frequently offered foods different from programs in the mainland, reflecting ethnic and cultural food preferences. In terms of DG's adequate protein was present, cholesterol content was satisfactory but meals had excess percent energy from fat as well as excess energy from saturated fat, high sodium and a lower than recommended level of energy from carbohydrate. In terms of RDA's meals had prescribed levels of vitamin A, vitamin B12, vitamin C, calcium, folacin, magnesium, phosphorus and potassium. Below prescribed levels included vitamin B6, copper, vitamin E, energy, fiber, iron, niacin and zinc. CONCLUSIONS: While differences in food preferences exist between foods available in the Breakfast and Lunch Programs in Puerto Rican and U.S., schools, they have similar strengths and weaknesses when compared to compliance with U.S. Dietary Guidelines and with recommended dietary allowances.

Adolescent↗

PubMed1993

Health care reform: managed competition and beyond.

Since the election, the health care reform debate has focused on three broad features: implementation of managed competition, changes in the tax treatment of health insurance, and the imposition of budget caps or targets. The basic element of managed competition is the creation of sponsors who act as collective purchasing agents for large groups of individuals. One of the potentially most politically difficult issues in implementing any health care reform proposal is likely to be defining the minimum standard benefit package. It will determine the costs society bears, the income of providers, the health of many individuals, and the attributes of a workable health care reform package. Managed competition is intended to foster competition among health plans on the basis of cost and quality. The measures of quality actually employed in the health care system will determine in large part the incentives faced by insurers, providers, and consumers. The problem of adverse selection is potentially the most important issue in reforming the health insurance market. If individuals can opt not to purchase health benefits, poorer risks will be more likely to purchase health insurance than good risks, and at minimum the price of these benefits will be higher than would otherwise be the case. Managed competition requires that individuals share at least some of the financial consequences of their choices among health plans. As a result, most managed competition proposals change the tax code by limiting the exclusion of employer contributions to health insurance from worker's taxable income. Changing the health insurance market, mandating employer health benefits, and changing the tax code may have significant effects on the health care delivery system, but they are unlikely to reduce health care cost inflation in the near term. One of the proposals for restraining the growth in health care costs is the imposition of a budget on the amount spent on health care services. The combination of the constraints placed on federal governmental action by the budget and the significant political problems involved in reaching a consensus on the important elements of health care reform may limit the ability of the federal government to implement national health care reform in the near term. As a result, individual states may be encouraged by the federal government to continue to experiment with their own health reform programs.

Budgets↗

PubMed1999

Conference report. Measuring and improving the quality of care in health plans.

BACKGROUND: More than 200 health care policymakers and researchers, clinicians, quality professionals, and other representatives of managed care organizations, government, and academia, attended the fifth annual Building Bridges conference, "The Health Care Puzzle: Using Research to Bridge the Gap Between Perception and Reality," in Chicago, April 11-13, 1999. Sponsored by the American Association of Health Plans and the Agency for Health Care Policy and Research--and now, the Centers for Disease Control and Prevention--these annual conferences are intended to promote research in measuring the quality and effectiveness of the services health plans provide. Selected plenary sessions from the conference are represented in this report. KEYNOTE ADDRESS: "Three worthy objectives" for managed care-harmonize practice guidelines, develop evidence-based copays or price structure for drugs, and demystify medical necessity--were discussed. PLENARY: A POPULATION HEALTH PERSPECTIVE: Population-based care is designed to identify effective clinical and service interventions and ensure their efficient delivery, identify ineffective interventions and minimize their use, and monitor outcomes and change practice if outcomes are suboptimal. Yet certain questions need to be asked about how to put this strategy in place, especially Why should any individual or potential patient be willing to be treated in a population-based delivery system? THE FINANCIAL AND SCIENTIFIC EVIDENCE BEHIND PREVENTION: The concepts of scientific evidence and financial evidence for prevention were reviewed and applied in scenarios of the effectiveness and cost-effectiveness of selected preventive care services. Education efforts are needed to promote the use of effective interventions and encourage questioning of interventions with unproven or less important effectiveness and poor cost-effectiveness.

Health Policy↗

PubMedDate not supplied

The role of the FDA in the effort against AIDS.

The Food and Drug Administration has instituted several pro-active measures to expedite the review of treatments, diagnostics, and vaccines for AIDS and related conditions. In particular, the agency has established a special designation--1-AA--for a potential AIDS product which gives top priority to its review. This special expedited review process for AIDS products has provided for greater cooperation between their sponsors and FDA's reviewers. AIDS products also receive prompt consideration for orphan product status--a status providing financial incentives to the developers of treatments for certain rare and complex diseases. FDA's special procedures for AIDS drugs have resulted in several major advances in available AIDS treatments. Foremost among these was the FDA's review and approval of zidovudine (commonly known as AZT) as the first effective palliative for AIDS within 107 days--an agency record. Similarly, the agency quickly evaluated and approved ELISA and Western blot diagnostic kits for detecting the presence of HIV antibody. These test kits have made an important contribution to safeguarding the nation's blood supply. The agency has also instituted new "treatment" investigational new drug regulations to allow earlier pre-approval distribution of promising experimental treatments to patients with immediately life-threatening conditions, including persons with AIDS. Under this system and its earlier prototype, eligible AIDS patients were able to receive pre-approval treatment with zidovudine and trimetrexate (an experimental drug for the treatment of AIDS patients with Pneumocystis carinii pneumonia who have experienced severe adverse reactions using standard approved therapies). The agency has made institutional reforms to effectively streamline the review of candidate AIDS treatments and vaccines. Two new centers within the agency have been established for the processing of drug and biologics. In addition,reviewing divisions have been created within these centers to give specialized attention to drugs and biologics designed to treat AIDS or related conditions.These efforts and the other aforementioned reforms, in part, have lead to the initiation of more than 100 ongoing clinical studies of potential drugs for AIDS and related conditions, as well as the clinical testing of two candidate vaccines against HIV. In other areas, FDA has increased inspections of the manufacturing and processing of condoms and begun a surveillance and sampling program to insure the quality of latex surgical gloves. The agency has worked with other authorities to move against quack AIDS products and to educate the public concerning this health fraud.FDA hopes that through all these efforts it can help researchers in government, academia, and industry advance the development, testing, and review of safe and effective therapies, preventatives,and diagnostics for AIDS and related conditions.

Acquired Immunodeficiency Syndrome↗

PubMedDate not supplied

Financing health care at the local level: the community drug funds of Honduras.

In response to UNICEF's Bamako Initiative, hundreds of privately run Community Drug Funds were established in Honduras during the 1990s, generally under the auspices of a non-government organization and usually with the financial assistance of international agencies. Honduras' Community Drug Funds (CDF) are rotating drug funds intended to: (1) serve as a means of increasing access to care in isolated rural populations, (2) promote the more rational use of medicines and (3) promote community participation in the financing and oversight of primary health care activities. This study is the first to analyse empirically the impact and efficiency of these institutions, relying upon primary data obtained from a survey of 51 of the 450 active CDFs in Honduras. Archival data from Ministry of Health and other sources were also analysed. The structure, operations, and impact of CDFs are detailed, with special attention given to access and quality of care issues. The study found that CDFs are rapidly becoming under-capitalized because of basic management problems, principally in pricing and in medicine purchasing practices. These shortcomings, and more generally, increasing financial pressures on NGO sponsors, are negatively affecting quality and access to care. Given the rate of erosion in CDF assets, unless they are recapitalized, the current average estimated lifespan of a CDF is 5.5 years. If these funds are to be sustainable, changes in their financing, training and supervision will be required. In addressing these issues, Honduran health policy-makers must decide how best to balance the competing goals of holding down costs, while maintaining adequate quality and improving access to care.

Community Participation↗

PubMed2001

Executive Summary of the National Cancer Institute Workshop: Highlights and recommendations.

Prostate cancer chemoprevention represents a relatively new and promising strategy for reducing the immense public health burden of this devastating cancer of men in the United States and Western societies. Chemoprevention is defined as the administration of agents (drugs, biologics, and natural products) that modulate (inhibit) one or more steps in the multistage carcinogenesis process culminating in invasive adenocarcinoma of the prostate. In 2000, there were an estimated 170,000 new cases of prostate cancer and 31,000 deaths in the United States. During the past decade, the National Cancer Institute (NCI) organized the chemoprevention research program and began testing the first generation of promising agents (eg, 4-(hydroxy)-fenretinide [4-HPR], difluoromethylornithine [DFMO], antiandrogens) in high-risk cohorts and launched the first-large scale US phase 3 primary prevention trial, known as Prostate Cancer Prevention Trial (PCPT-1), in 18,000 average-risk men (age more than 55 years and prostate-specific antigen [PSA] less than 3 ng/mL) treated for 7 years with finasteride or placebo. In the summer of 1998, the NCI Prostate Cancer Progress Review Group (PRG) Report to the director of NCI was published in response to the leadership of the prostate cancer advocacy community in conjunction with Congress. To further elucidate and address critical issues identified in this report and to develop a research agenda for the newly created Prostate and Urologic Cancer Research Group in the Division of Cancer Prevention at NCI, the NCI organized the workshop "New Clinical Trial Strategies for Prostate Cancer Chemoprevention." The major objectives were to promote understanding and cooperation among the NCI, US Food and Drug Administration (FDA), academia, pharmaceutical industry, and the public regarding new opportunities for clinical prevention trials for prostate cancer. The workshop was divided into three concurrent breakout panels and a fourth joint integrative panel. The workshop addressed multiple key areas identified in the PRG report in the following panels: (1) Molecular Targets and Promising Agents in Clinical Development; (2) Intermediate Endpoint Biomarkers for Prevention Trials; (3) High-Risk Study Populations for Prevention Trials, and (4) Preventive Clinical Trial Designs and Regulatory Issues. Expert panelists were drawn from leading academic, pharmaceutical, and government scientists in basic research and clinical investigation. Key pharmaceutical, biotechnology, academic, and National Institutes of Health scientists presented overviews of their new agents and products in clinical development (representing the next generation of promising agents). Senior FDA physicians from the Center for Drugs and Center for Biologics presented on current standards for new drug and biologic approval for chemoprevention efficacy. Some of the key topics included recent advances in the state of knowledge of promising agents in the clinic based on molecular targets as well as bottlenecks in drug development for pharmaceutical sponsors; strategic modulable biomarkers that can serve as primary endpoints in phase 1/2 trials to assess preventive efficacy; high-risk cohorts with precancer (high-grade prostatic intraepithelial neoplasia) and representative clinical trial designs that are ready for immediate translation into efficient prevention trials, such as Bayesian sequential monitoring for early assessment of biologic activity and factorial designs for assessment of multiagent combinations. Finally, each expert panel generated recommendations for areas of future research emphasizing opportunities and infrastructure needs.

Anticarcinogenic Agents↗

PubMedDate not supplied

Organizational development and privatization: a Bolivian success story.

This article presents a case study of a US Agency for International Development-sponsored privatization effort in Bolivia. This privatization effort differs from AID's more common approach in that rather than merely helping already existing organizations to expand, this project has created a new organization. More ambitious and encompassing, this approach is also preferable because it directly addresses one of the most serious bottlenecks to economic development, viz., organizational development. The article describes the evolution of PROSALUD, a private, non-profit network of 17 community-sponsored health centers. The article describes factors and characteristics which have either conditioned or have directly contributed to PROSALUD's success. First, PROSALUD's health care environment is analysed, starting with a broad brush profile of select characteristics and trends which exist throughout the health sector of Bolivia, then narrows the focus to the local health sector. The structure and operations of PROSALUD are then analysed, focusing on the organization's managerial practices and financing and the series of tradeoffs it has been forced to strike: in its pricing strategy, between striving for financial viability and maintaining access to care; between, on the one hand, responding to community needs and demands and improving coverage by opening more facilities, and, on the other hand, focusing managerial efforts and outreach on a more limited number of clinics and neighborhoods; between providing a socially desirable mix of services--in particular, continuing to provide a great deal of free preventive care--and focusing care on more lucrative curative services; between maintaining commitments to neighborhoods and communities and eliminating the less economically viable (especially rural) clinics.

Bolivia↗

PubMed2005

The tissue microarray data exchange specification: a document type definition to validate and enhance XML data.

BACKGROUND: The Association for Pathology Informatics (API) Extensible Mark-up Language (XML) TMA Data Exchange Specification (TMA DES) proposed in April 2003 provides a community-based, open source tool for sharing tissue microarray (TMA) data in a common format. Each tissue core within an array has separate data including digital images; therefore an organized, common approach to produce, navigate and publish such data facilitates viewing, sharing and merging TMA data from different laboratories. The AIDS and Cancer Specimen Resource (ACSR) is a HIV/AIDS tissue bank consortium sponsored by the National Cancer Institute (NCI) Division of Cancer Treatment and Diagnosis (DCTD). The ACSR offers HIV-related malignancies and uninfected control tissues in microarrays (TMA) accompanied by de-identified clinical data to approved researchers. Exporting our TMA data into the proposed API specified format offers an opportunity to evaluate the API specification in an applied setting and to explore its usefulness. RESULTS: A document type definition (DTD) that governs the allowed common data elements (CDE) in TMA DES export XML files was written, tested and evolved and is in routine use by the ACSR. This DTD defines TMA DES CDEs which are implemented in an external file that can be supplemented by internal DTD extensions for locally defined TMA data elements (LDE). CONCLUSION: ACSR implementation of the TMA DES demonstrated the utility of the specification and allowed application of a DTD to validate the language of the API specified XML elements and to identify possible enhancements within our TMA data management application. Improvements to the specification have additionally been suggested by our experience in importing other institution's exported TMA data. Enhancements to TMA DES to remove ambiguous situations and clarify the data should be considered. Better specified identifiers and hierarchical relationships will make automatic use of the data possible. Our tool can be used to reorder data and add identifiers; upgrading data for changes in the specification can be automatically accomplished. Using a DTD (optionally reflecting our proposed enhancements) can provide stronger validation of exported TMA data.

AIDS-Related Complex↗

PubMed2000

Errors in medicine: problems and solutions for managed care.

Extrapolating data from 2 large retrospective studies, the IOM report provides an estimate of errors in health care. While these estimates have been taken from inpatient experience and not from ambulatory care (the site of most HIV/AIDS care today), these estimates have stimulated discussion and action on the part of the Federal government and health care organizations to improve patient safety. HIV/AIDS care lends itself to electronic solutions as suggested in the IOM report. Providers are under increasing pressure to do more clinical work and documentation in an era of shrinking resources. Managing the care of patients with HIV/AIDS requires frequent visits and necessitates documentation of both clinical and nonclinical information and considerable coordination and tracking of care activities by all members of the care team, with the goals of good outcomes and cost-effectiveness. Recent studies suggest that the current standard of HIV care is effective and cost-effective. Today's electronic technologies can help sustain these good outcomes by helping to manage large volumes of critical health information more efficiently. Electronic management of health information requires a change in work patterns and a significant capital investment for health organizations. Federal standards for management of electronic health information are in early implementation stages. To start the process, managed care organizations and HIV/AIDS providers should become familiar with the capabilities of electronic health information systems, begin the planning and needs assessment processes, and begin to lay the infrastructure needed for such systems.

Acquired Immunodeficiency Syndrome↗

PubMed1993

[Association between participation in health check and visiting medical facilities in residents in a rural town].

Participants in a community secondary prevention action sponsored by the local government were compared with non-participants with respect to utilization of medical facilities for medical examinations. The study sample consisted of 1,013 males and 1,042 females aged 40 years or over, in a rural town in Kyoto prefecture, who were members of the National Health Insurance. Data from National Health Insurance records, such as date of consultation and type of medical examinations, were analyzed. The secondary prevention action sponsored by the town consisted of a multiphasic health check for circulatory or other chronic diseases, and screenings for tuberculosis and cancers of the stomach, lung, breast and cervix. Medical examinations included urine test, blood cell count, electrocardiography, laboratory tests for serum transaminases, serum glucose, and fecal occult blood, X-ray or endoscopy of the stomach, chest X-ray, mammography, and cervical cytology. Results of the study showed that those who attended the town sponsored secondary prevention action were more likely to utilize local medical facilities, and those who did not participate were likely to visit facilities outside the town. Medical facilities, both local and outside the town, had a larger proportion of examinations corresponding to health examinations or stomach cancer screening than the town office, however, the town office had a larger proportion of lung or cervical cancer screening. The health examination and stomach cancer screening in the town office, and in the medical facilities appeared to be redundant while lung and cervical cancer screening were complemented tests at medical facilities. When these examinations are targeted as modifying factors in the natural history of diseases, consideration should be given to both the records of secondary prevention actions as well as medical records of other medical facilities that may be utilized.

Adult↗

PubMed1984

Use of sealants: societal and professional factors.

At present, sealant use continues at a low level in private practice by dentists and hygienists, and is moderate in community programs although there is high interest in their use in public health settings. Widespread delegation of sealant application to hygienists has not occurred even though the majority of state dental practice acts allow it, and even though practicing hygienists are highly interested in applying sealants. Use in federally sponsored programs is minimal or nonexistent. Information about sealants and adequate clinical experience in their application appear minimal in dental training institutions, and few opportunities have existed for continuing education. Generally, knowledge about sealants among dentists is low; many hold doubtful opinions. Insurance carriers, including commercial, provider, and governmental programs, appear reluctant to reimburse for sealants without purchaser demand and organized dentistry's blessings. Although society emphasizes patient rights to informed consent, few opportunities exist for the public, including group insurance purchasers and union negotiators, to learn about sealant use in conjunction with appropriate fluoride use. Public educational materials are sparse. Manufacturer marketing efforts at present, aimed at providers alone, are at best minimal, with a few exceptions; those targeting the public are nonexistent. Organized dentistry's Council statements may have contributed to a constriction, to date, in the flow of public information about sealants from industry. Lack of communication, or miscommunication, between practitioners and dental scientists has resulted in much misinformation and confusion about the value of sealants and their use. And, the contemporary status of dental manpower and the economy of dental practice in the private sector appear to have provided an infertile environment for acceptance of sealants as a primary preventive technology. In the public sector, interest in sealants is high but two primary constraints are inadequate manpower and lack of financial resources. Clearly there has been a time-lag in the adoption of new sealant products, and it is apparent that no one factor can explain this lag; rather, many complex factors must be taken into account simultaneously. Extent of need does not appear to have influenced use, to date. Often, social change is slow, and all things considered, the lag observed for sealants may not be totally unreasonable.(ABSTRACT TRUNCATED AT 250 WORDS)

American Dental Association↗

PubMed2001

Health care in the United States: current and future challenges.

The last time the United States experienced rapid increases in health care expenditures in the 1980s, the solution was widespread adoption of managed care by employer-sponsored health plans. To a lesser degree, managed care approaches were adopted for some Medicaid and Medicare enrollees. By the mid-1990s, new Medicare reimbursement policies and the widespread adoption of managed care plans had substantially reduced the growth rate of health care expenditures. All published studies show that HMOs and other managed care plans have delivered health care of equal or better clinical quality to traditional indemnity insurance plans at a lower cost. Yet as the economy strengthened during the latter '90s, concerns about overall health care costs lessened, and the public became less willing to accept restrictions on the enrollee's choice of physician and the physician's treatment choices. Public opinion turned against the concept of managed care as a result of backlash from both physicians and consumers. Government mandates altered the ability of managed care to deliver on the promise of higher quality at a reduced cost. Today, health care costs are again rising. The United States is spending significantly more per capita on health care than are other developed nations, with no demonstrable improvement in health outcomes. Estimates suggest that in the next 30 years, health care costs will again rise at a rate faster than that of the economy. Further, rising costs will reflect the impact of an aging population, with more than 20 percent of individuals 65 years or older by the year 2030. Thus, it appears we are again headed for a crisis. However, the environment has changed: As a result of the experience of the last 10 years, the public is now less willing to accept changes to the health care system, and the concept of managed care has negative connotations. Consequently, the crisis may potentially be even worse than that we experienced a decade ago if we are unable to find ways to control health care expenditures.

Cost Control↗