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PubMed2000

An epidemic without illness. Using dna markers to model infection.

PURPOSE: Combining molecular biology with infection control interventions can increase compliance and allow objective measurement of effectiveness. We developed a group of PCR detectable non-infectious DNA markers that can be used to model infection and provide immediate feedback on hygiene practices in institutional settings. In previous studies, we illustrated that the markers were spread in the environment in the same manner as infectious particles.METHODS: We are conducting a prospective study in 10 child care centers in order to 1) confirm that the DNA markers are valid surrogates for bacteria and viruses; 2) identify specific foci of contamination and modes of transmission; 3) illustrate the effectiveness of infection control programs utilizing the DNA markers. Centers are randomized to receive an interactive educational infection control intervention or a standard immunization intervention. The DNA markers are introduced into the center and the rate of dispersion of the DNA markers is compared with directly observed changes in hygiene behavior among the staff.RESULTS: Initial results indicate that the markers can be removed mechanically by hand washing and that common over-the-counter cleaners are effective in inactivating the markers. Toys, countertops and doorknobs appear to be more important as infectious reservoirs than brief casual contact. Data from the prospective study will be available prior to September, 2000.CONCLUSIONS: This novel approach utilizing an objective measurement will be used to identify the interaction between behavior and environmental reservoirs of infection and drive future strategies for infection control.

Journal Article↗
PubMed1997

Development of performance measures for seven chronic diseases. Health Outcomes Work Group of the Pharmaceutical Research and Manufacturers of America.

BACKGROUND: In 1994 the Washington, DC-based Pharmaceutical Research and Manufacturers of America (PhRMA) initiated a project to develop performance measures for seven chronic diseases-chronic obstructive pulmonary disease, chronic stable angina, depression, diabetes mellitus, hypercholesterolemia, hypertension, and rheumatoid arthritis-that are commonly treated with pharmaceuticals. The project was coordinated by PhRMA's Health Outcomes Work Group (HOWG), an ad hoc committee that addresses issues concerning health outcomes research. METHODOLOGY: For each of the seven diseases, HOWG assembled a panel of clinical experts from the pharmaceutical industry to develop the quality-of-care performance measures. HOWG wanted the measures to be ones that health plans could use to improve the quality of care, that were based on reliable data that could be standardized to account for patient population differences, and that were practical to institute (not cost prohibitive). By the end of a 1 1/2-day working session, each panel had developed at least one preliminary performance measure. Following the panels' meeting, background literature searches were conducted and supporting documentation was obtained. The panels then sent the revised performance measures to appropriate professional organizations for informal review. Another round of revisions was then completed. CHALLENGES AND NEXT STEPS: HOWG's experience in developing these measures, which contain either or both the important clinical processes and outcomes for the respective diseases, has highlighted current challenges in the performance measure arena, such as the availability, validity, and varying sources of data. The PhRMA performance measures should be subjected to further external review and pilot tests before implementation.

Arthritis, Rheumatoid↗
PubMedDate not supplied

Diagnosis and risk stratification in coronary artery disease: nuclear cardiology versus stress echocardiography.

Both myocardial perfusion imaging and stress echocardiographic techniques have evolved tremendously during the past decade and now play a major role in the evaluation and management of patients with known or suspected coronary artery disease (CAD). Each method requires clinical experience and technical expertise, and each has potential advantages and disadvantages that, in a given institution or practice setting, may make one or the other perform more accurately, more efficiently, or more cost-effectively. Stress echocardiography offers a relatively cost-effective method for cardiac imaging, and this technique is often viewed as a lower-cost alternative to myocardial perfusion imaging. The available data reported in the literature indicate that stress echocardiography and myocardial perfusion imaging provide comparable results for the diagnosis of CAD. However, in many situations the presence or absence of CAD is less important than determining the extent and severity of disease and identifying patient subgroups at high risk and low risk. From this perspective, myocardial perfusion imaging provides greater sensitivity than stress echocardiography for detecting the presence and extent of ischemic, jeopardized myocardium and for identifying viable yet dysfunctional myocardium. This greater sensitivity translates into more reliable prognostic information than that provided by stress echocardiography. This ability to predict which patients are at risk of subsequent cardiac events, and which are at extremely low risk and can be followed safely without further evaluation, may reduce the long-term costs of treating CAD, even though the short-term costs of stress echocardiography may be lower.

Coronary Disease↗
PubMed2003

DOTS-Plus for multidrug-resistant tuberculosis in the Philippines: global assistance urgently needed.

SETTING: The Philippines, a high burden country for tuberculosis (TB). STUDY DESIGN: Health Operational Study. OBJECTIVE: To describe preliminary data from the Makati Medical Center (MMC)-DOTS Plus pilot project. METHODS: Patients were consecutively enrolled after confirmation of MDR-TB status. Individualized treatment regimens were based on drug susceptibility testing and history of previous intake for the other drugs that were not tested. Treatment outcome in those who had completed at least 18 months of therapy and interim outcome for those who received more than 12 months but less than 18 months were analyzed. RESULTS: One hundred forty-nine patients with MDR-TB were enrolled from April 1999 to 30 May 2002 at the MMC DOTS Clinic. Referrals were from private institutions and practicing physicians in 73.2% of cases. Approximately 30% of isolates tested were resistant to all five first-line drugs, 39.4% to four, 16.8% to three, 12.1% to two. Fluoroquinolone resistance was noted in 40.9% of all the isolates, including 54.5% of those resistant to five drugs and 34.6% of those resistant to four drugs. The outcome of 23 patients who completed therapy and 62 who have received more than 12 months therapy showed cure and likely cure in 73.4% of cases and failure in 3.8% and likely failure in 6.3%. Death occurred in 3.8% and default was observed in 11.4%. CONCLUSION: The MMC DOTS-Plus pilot project is a public-private collaboration in TB Control. Response to therapy was encouraging. Complete subsidy of medicines and laboratory and clinic services and DOT were essential in the successful implementation of the program. DOTS-Plus and DOTS should go hand in hand in TB control if MDR-TB is highly prevalent.

Adolescent↗
PubMed2000

Collective actions by physicians that do not endanger patients.

Exploitation of resident physicians still occurs and can result in working conditions so unfavorable that patients are endangered. Because residents are vulnerable to exploitation, and because they are not fully accountable for patient care or for fully developed professionalism until they have completed their training, for just ends it is morally acceptable for residents to strike. Given that the ultimate responsibility for every patient rests not with the residents but with the attending and staff physicians, in the event of a resident strike the attending and staff physician supervisors should cover patient care, at least with respect to essential services. It is not morally acceptable for attending or staff physicians who are employees to strike. Attending and staff physicians should make every effort to resolve concerns about patient care without the use of confrontation. However, it may be necessary to consider collective actions to secure certain professional interests, including an interest in patient care. For such ends, patient endangerment is an unacceptable means and contrary to the professional virtue of altruism. The strategy for a just collective action is to identify the things that physicians normally do for their employer and collectively to withhold all of them, with the single exception of patient care.

Collective Bargaining↗
PubMedDate not supplied

The prehospital emergency care system in Mexico City: a system's performance evaluation.

INTRODUCTION: Mexico City has one of the highest mortality rates in Mexico, with non-intentional injuries as a leading cause of death among persons 1-44 years of age. Emergency medical services (EMS) in Mexico can achieve high levels of efficiency by offering high quality medical care at a low cost through adequate system design. OBJECTIVE: The objective of this study was to determine whether the prehospital EMS system in Mexico City meets the criteria standards established by the American Ambulance Association Guide for Contracting Emergency Medical Services (AAA Guide) for highly efficient EMS systems. METHODS: This retrospective, descriptive study, evaluated the structure of Mexico City's EMS system and analyzed EMS response times, clinical capacity, economic efficiency, and customer satisfaction. These results were compared with the AAA guide, according to the soc ial, economic, and political context in Mexico. This paper describes the healthcare system structure in Mexico, followed by a description of the basic structure of EMS in Mexico City, and of each tenet described in the AAA guide. The p aper includesdata obtained from official documents and databases of government agencies, and operative and administrative data from public and private EMS providers. RESULTS: The quality of the data for response times (RT) were insufficient and widely varied among providers, with a minimum RT of 6.79 minutes (min) and a maximum RT of 61 min. Providers did not define RT clearly, and measured it with averages, which can hide potentially poor performance practices. Training institutions are not required to follow a standardized curriculum. Certifications are the responsibility of the individual training centers and have no government regulation. There was no evidence of active medical control involvement in direct patient care, and providers did not report that quality assurance programs were in place. There also are limited career advancement opportunities for EMS personnel. Small economies of scale may not allow providers to be economically efficient, unit hours are difficult to calculate, and few economic data are available. There is no evidence of customer satisfaction data. CONCLUSIONS: Emergency medical services in Mexico City did not meet the AAA requirements for high-quality, prehospital, emergency care. Coordination among EMS providers is difficult to achieve, due, in part, to the lack of: (1) an authoritative structure; (2) sound system design; and (3) appropriate legislation. The government, EMS providers, stakeholders, and community members should work together to build a high quality EMS system at the lowest possible cost.

Efficiency, Organizational↗
PubMed2003

Development of a job-specific FCE protocol: the work demands of hospital nurses as an example.

Musculoskeletal disorders often result in employee disability leaves and sickness-related absenteeism in the workplace. Professional evaluations of an employee's capacity to work require additional support by means of Functional Capacity Evaluation (FCE) methods. However, most FCE methods assess general physical capacity and, because of fixed test procedures, testing times range between 4 and 6 h for up to several days. For return to work (vocational rehabilitation), the tests need to reflect the employees' specific work demands more precisely. This study aims to develop a job-specific FCE protocol on the Ergos Work Simulator for hospital nurses. In developing the contents of this specific protocol, hierarchical task analyses were performed with 20 nurses in four departments of a university medical center. A job-specific test protocol was developed that consisted of five steps. In this process, the original test protocol was analyzed first. Secondly, categorization of physical risk factors for work-related musculoskeletal disorders revealed 16 possible combinations of activity, posture, and load. Finally, duration and frequencies during one working day of these combinations were coupled to the Ergos test panels. The nurse-specific test protocol lasts 90 min. It was possible to develop a job-specific protocol, using on-site observations as the input. Compared to the original Ergos protocol, the external validity of the new job-specific protocol has improved: it simulates the functional capacity that nurses need to perform their job in a realistic way. The testing time of the original Ergos protocol is four times longer compared to the new job-specific protocol.

Computer Simulation↗
PubMed2004

Religious involvement, coping, social support, and psychological distress in HIV-seropositive African American mothers.

This study used a cross-sectional design to examine the role of religious involvement within a stress-process framework. Participants were 252 urban, low-income HIV-seropositive African American mothers. The relationships among religious involvement, stress, coping responses, social support, and psychological distress were examined using structural equation modeling. The number of stressors reported by the mother was related to greater religious involvement, which in turn was negatively related to psychological distress. Furthermore, the results suggest that social support, active coping, and avoidant coping responses mediated the relationship between religious involvement and psychological distress. According to the present results, interventions to attenuate psychological distress in HIV-seropositive African American mothers might focus on increasing social support, promoting active coping, and decreasing avoidant coping. The present findings suggest that this may be accomplished, in part, by promoting involvement in religious institutions and practices. However, in light of the cross-sectional design used in the present study, and given that religion may have both positive and negative consequences, further research is needed to determine the extent to which promoting religiosity may increase or alleviate distress.

Adaptation, Psychological↗
PubMed2003

The clinical thrombosis center and clinical thrombologist: a new US health systems paradigm for the management of venous thromboembolic disease.

New paradigms for the diagnosis, prophylaxis, acute treatment, and ongoing management of patients with venous thromboembolic disease (VTE), a better understanding of the genotypic and phenotypic mechanisms of thrombophilic states, and the possibility of a greatly expanded armamentarium of antithrombotic therapies are necessitating a more formalized and systematic approach to VTE management. This has required many US healthcare institutions to develop piecemeal approaches in management models for VTE utilizing local champions from a variety of subspecialties. Development of a formalized Clinical Thrombosis Center from an already established Anticoagulant Management Service utilizing a clinical thrombologist, a new role for a physician who has developed expertise in anticoagulation and VTE management, presents a new paradigm in which this disease may be approached at a formalized, institutional level. Thus the clinical thrombologist working through a Clinical Thrombosis Center can develop a system-of-care approach to link the rapid advances in the field of thromboembolism to clinical applications, formulate evidence-based disease management guidelines, and conduct patient-oriented translational clinical research in VTE.

Cardiology↗
PubMed2000

[Does nursing need its own ethics?].

In contrast to a medicine and medical ethics dominated by the physician, nurses claim more professional autonomy, domains of independent responsibility and recognition of their own moral judgment and ethical reflection. In my article I endorse these claims, but I object to the widespread opinion that their fulfillment requires a nursing ethics of its own, in the sense of a specific moral theory for nursing. Such a "special ethics" would be counterproductive to the concerns of nurses, and just as mistaken as a special medical or physicians ethics. Instead, a critique of medicine on the basis of a general ethics is required both for nurses and physicians. Part I presents arguments against mistaken conceptions of a special nursing ethics. Part II outlines elements of a general ethics for medicine and nursing. Part III explains my understanding of an ethical critique of medicine, which is founded upon the distinction of three conceptual dimensions of medicine: as science, institution and practice. This critique focuses the ethical attention on the life situation of the patient. Consequences for argumentative support and political fulfillment of the nurses' claims mentioned will thereby become evident.

Ethics, Medical↗
PubMed1999

Anaesthesia clinical directors in the United Kingdom: organisation, objectives and support needs.

A postal survey of all 269 acute hospital trusts identified in the United Kingdom was carried out to study the work of Clinical Directors of anaesthesia. Initial responses from 163 Clinical Directors and 129 completed questionnaires were analysed. Four main areas of concern revealed by the survey were contracts and objectives, funding of managerial sessions, access to information and perceived need for support. Most Clinical Directors had no job description and most had no formal written objectives, despite a substantial body of advice that these should be provided. There was generally substantial underfunding of managerial hours compared with those actually worked and approximately 20% of Clinical Directors surveyed had no funding for managerial duties. Clinical Directors' ratings of the information available to assist their decision making were also a cause of concern. Clinical Directors perceived that they need better networking, more training particularly on human resource management and improved management information.

Adult↗
PubMed2004

A prospective multicentre study of pharmacist initiated changes to drug therapy and patient management in acute care government funded hospitals.

AIMS: To determine the cost savings of pharmacist initiated changes to hospitalized patients' drug therapy or management in eight major acute care government funded teaching hospitals in Australia. METHODS: This was a prospective study performed in eight hospitals examining resource implications of pharmacists' interventions assessed by an independent clinical panel. Pharmacists providing clinical services to inpatients recorded details of interventions, defined as any action that directly resulted in a change to patient management or therapy. An independent clinical review panel, convened at each participating centre, confirmed or rejected the clinical pharmacist's assessment of the impact on length of stay (LOS), readmission probability, medical procedures and laboratory monitoring and quantified the resultant changes, which were then costed. RESULTS: A total of 1399 interventions were documented. Eight hundred and thirty-five interventions impacted on drug costs alone. Five hundred and eleven interventions were evaluated by the independent panels with three quarters of these confirmed as having an impact on one or more of: length of stay, readmission probability, medical procedures or laboratory monitoring. There were 96 interventions deemed by the independent panels to have reduced LOS and 156 reduced the potential for readmission. The calculated savings was $263 221 for the eight hospitals during the period of the study. This included $150 307 for length of stay reduction, $111 848 for readmission reduction. CONCLUSIONS: The annualized cost savings relating to length of stay, readmission, drugs, medical procedures and laboratory monitoring as a result of clinical pharmacist initiated changes to hospitalized patient management or therapy was $4 444 794 for eight major acute care government funded teaching hospitals in Australia.

Adolescent↗
PubMedDate not supplied

Stage I-II endometrial adenocarcinoma evolution of therapeutic paradigms: the role of surgery and adjuvant radiation.

The objective was to review the English-language literature regarding the utility of adjuvant radiation therapy following surgery for endometrial adenocarcinoma. An OVID software (Ovid Technologies, Inc., New York, NY) search of Medline articles from 1975 to 2001 was conducted using the keywords "endometrial neoplasm," "surgery," and "radiation therapy." The papers were assessed with regard to (a) extent of surgical staging (b) type of adjuvant radiotherapy utilized: external vs. brachytherapy vs. combination therapy; and (c) whether the patients were treated as part of prospective trial or reported as a descriptive series reflecting an institution's practice pattern. Survival rates are excellent for patients with early stage disease treated in either paradigm of extended-surgical staging with more restricted use of the adjuvant therapy or simple hysterectomy bilateral salpingoophorectomy with more frequent use of adjuvant radiotherapy. All three prospective-randomized trials (PRCT) have shown an improvement in local control but no overall survival benefit for the entire accrued group. All three PRCTs have shown a higher risk of disease recurrence in older patients or those with grade 3 histology or deep invasion. Each suggests there may be a survival benefit for the subset of patients with such high-risk features, but at present there is no prospective data that demonstrates adjuvant radiotherapy will improve the overall survival for the highest-risk subset of older patients with high-grade deeply invasive disease.

Adenocarcinoma↗
PubMed2003

The status of medical education in end-of-life care: a national report.

OBJECTIVE: To assess the status of medical education in end-of-life care and identify opportunities for improvement. DESIGN: Telephone survey. SETTING: U.S. academic medical centers. PARTICIPANTS: National probability sample of 1,455 students, 296 residents, and 287 faculty (response rates 62%, 56%, and 41%, respectively) affiliated with a random sample of 62 accredited U.S. medical schools. MEASUREMENTS AND MAIN RESULTS: Measurements assessed attitudes, quantity and quality of education, preparation to provide or teach care, and perceived value of care for dying patients. Ninety percent or more of respondents held positive views about physicians' responsibility and ability to help dying patients. However, fewer than 18% of students and residents received formal end-of-life care education, 39% of students reported being unprepared to address patients' fears, and nearly half felt unprepared to manage their feelings about patients' deaths or help bereaved families. More than 40% of residents felt unprepared to teach end-of-life care. More than 40% of respondents reported that dying patients were not considered good teaching cases, and that meeting psychosocial needs of dying patients was not considered a core competency. Forty-nine percent of students had told patients about the existence of a life-threatening illness, but only half received feedback from residents or attendings; nearly all residents had talked with patients about wishes for end-of-life care, and 33% received no feedback. CONCLUSIONS: Students and residents in the United States feel unprepared to provide, and faculty and residents unprepared to teach, many key components of good care for the dying. Current educational practices and institutional culture in U.S. medical schools do not support adequate end-of-life care, and attention to both curricular and cultural change are needed to improve end-of-life care education.

Attitude of Health Personnel↗