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PubMed1994

Purchasing for all: an alternative to fundholding.

OBJECTIVE: To evaluate general practitioner participation in a district health authority's purchasing work. DESIGN: Questionnaire study of 131 Hackney general practitioners and 33 senior health service managers; review of the minutes of 28 meetings of the Hackney General Practitioners' Forum and the contract between City and Hackney Health Authority and the St Bartholomew's NHS Trust. SETTING: Hackney General Practitioners' Forum. MAIN OUTCOME MEASURES: General practitioners' and managers' perceptions of how representative and effective the general practitioners' forum is; proportion of new quality targets and service developments contributed by general practitioners; main issues discussed by the forum and impact on district health authority policy. RESULTS: 99 (76%) general practitioners and 27 (82%) managers responded. Both groups perceived the forum as representative. 92% (24/26) of the managers thought the forum was effective but only 74% (70/95) of general practitioners did so, largely because some doubted that the forum was listened to 75% (103/138) of quality targets and 55% (16/29) of service developments planned in the 1993-4 contract were contributed by general practitioners. They also lobbied successfully for more resources for urology and community mental health services. CONCLUSIONS: Input into commissioning via a general practitioners' forum can be both representative and effective. General practitioners need to work closely to achieve a consensus and those involved need administrative support. The relation between general practice and public health medicine needs to be strengthened.

Attitude of Health Personnel↗
PubMed1994

General practitioners' views about the statutory annual practice report.

OBJECTIVE: To ascertain the views of primary care professionals about the current purpose, uses, potential, and workload implications of the statutory general practice annual report. DESIGN: Postal questionnaire survey. SETTING: General practices in the Northern region. SUBJECTS: All practices in the region that were singlehanded, fundholding, non-fundholding and with more than five partners, and a one in three random sample of all non-fundholding practices (n = 318). RESULTS: 263 practices responded (83%). The report took a median of 12 hours to produce (95% confidence interval 11 to 15 hours; interquartile range 7-35). The main perceived purpose of the report was to monitor practice activity (165 respondents; 63% (95% confidence interval 57% to 69%)), but 44 respondents (17%; 13% to 22%) produced it only because it was contractually required. Practices included statutory and non-statutory data in these reports and would have liked comparative practice activity information (155 respondents; 59%) and "good ideas" (165 respondents; 63%) fed back to them. Respondents would have liked the annual report used to improve practice development planning (122 respondents; 46% (40% to 52%)), to facilitate audit (115 respondents; 44% (38% to 50%)), and to influence resource allocation (104 respondents; 40% (34% to 46%)). One hundred and eighteen practices (45%; 39% to 51%) would produce an annual report even if not contractually required. Data collected were perceived to be already available elsewhere. CONCLUSIONS: Primary care professionals have concerns about the current annual report. They would prefer to collect relevant, standardised data which could lead to better audit, planning, and resource allocation.

Annual Reports as Topic↗
PubMed2002

Health promotion for adolescents in primary care: randomised controlled trial.

OBJECTIVES: To evaluate the effectiveness of inviting teenagers to general practice consultations to discuss health behaviour concerns and appropriate follow up care. DESIGN: Randomised controlled trial, with participants randomised to a consultation (intervention) or usual care (control). Questionnaires completed at baseline, 3 months, and 12 months. SETTING: Eight general practices in Hertfordshire, England. PARTICIPANTS: 1516 teenagers aged 14-15 years. INTERVENTION: Consultations with practice nurses to discuss health concerns and develop plans for healthier lifestyles. MAIN OUTCOME MEASURES: Mental and physical health, "stage of change" for health related behaviour, and use of health services. RESULTS: At baseline 970 teenagers completed questionnaires; 23% smoked, 35% had been drunk in the previous three months, 64% considered they ate unhealthily, 39% took little exercise, and 36% had possible depression. 41% (304) of teenagers invited attended for a consultation; over one third (112) were offered follow up care. More intervention group teenagers reported positive movement in stage of change for diet and exercise and in at least one of four behaviours (diet, exercise, smoking, drinking alcohol) at 3 months (41% v 31%, P<0.01), but this did not persist at 12 months. There was marginally more positive change in actual behaviour by intervention teenagers at 3 months (16% v 12%, P=0.06). Recognition of possible depression resulted in improved mental health outcomes at 3 and 12 months. 97% of attenders said they would recommend the intervention to a friend. CONCLUSIONS: Change in behaviour was slight but encouraging, and the intervention was well received and relatively cheap.

Adolescent↗
PubMed2005

Use of SPRAT for peer review of paediatricians in training.

OBJECTIVE: To determine whether a multisource feedback questionnaire, SPRAT (Sheffield peer review assessment tool), is a feasible and reliable assessment method to inform the record of in-training assessment for paediatric senior house officers and specialist registrars. DESIGN: Trainees' clinical performance was evaluated using SPRAT sent to clinical colleagues of their choosing. Responses were analysed to determine variables that affected ratings and their measurement characteristics. SETTING: Three tertiary hospitals and five secondary hospitals across a UK deanery. PARTICIPANTS: 112 paediatric senior house officers and middle grades. MAIN OUTCOME MEASURES: 95% confidence intervals for mean ratings; linear and hierarchical regression to explore potential biasing factors; time needed for the process per doctor. RESULTS: 20 middle grades and 92 senior house officers were assessed using SPRAT to inform their record of in-training assessment; 921/1120 (82%) of their proposed raters completed a SPRAT form. As a group, specialist registrars (mean 5.22, SD 0.34) scored significantly higher (t = - 4.765) than did senior house officers (mean 4.81, SD 0.35) (P < 0.001). The grade of the doctor accounted for 7.6% of the variation in the mean ratings. The hierarchical regression showed that only 3.4% of the variation in the means could be additionally attributed to three main factors (occupation of rater, length of working relationship, and environment in which the relationship took place) when the doctor's grade was controlled for (significant F change < 0.001). 93 (83%) of the doctors in this study would have needed only four raters to achieve a reliable score if the intent was to determine if they were satisfactory. The mean time taken to complete the questionnaire by a rater was six minutes. Just over an hour of administrative time is needed for each doctor. CONCLUSIONS: SPRAT seems to be a valid way of assessing large numbers of doctors to support quality assurance procedures for training programmes. The feedback from SPRAT can also be used to inform personal development planning and focus quality improvements.

Child↗
PubMed2000

Globalisation of tobacco industry influence and new global responses.

The globalisation of tobacco marketing, trade, research, and industry influence represents a major threat to public health worldwide. Drawing upon tobacco industry strategy documents prepared over several decades, this paper will demonstrate how the tobacco industry operates as a global force, regarding the world as its operating market by planning, developing, and marketing its products on a global scale. The industry has used a wide range of methods to buy influence and power, and penetrate markets across the world. It has an annual turnover of almost US$400 billion. In contrast, until recently tobacco control lacked global leadership and strategic direction and had been severely underfunded. As part of moving towards a more sustainable form of globalisation, a global enabling environment linked to local actions should focus on the following strategies: global information management; development of nationally and locally grounded action; global regulation, legal instruments, and foreign policy; and establishment of strong partnerships with purpose. As the vector of the tobacco epidemic, the tobacco industry's actions fall far outside of the boundaries of global corporate responsibility. Therefore, global and local actions should not provide the tobacco industry with the two things that it needs to ensure its long term profitability: respectability and predictability.

Advertising↗
PubMed1987

Cataract prevalence study--an Indian experience.

Study of cataract epidemiology has a special significance in prevention of cataract particularly in view of its high prevalence, and the exorbitant costs involved in its management. The broad objective was to estimate the magnitude and identify risk factors for future interventions. Such studies also help in planned development of manpower and physical infrastructure, besides making an estimation for operative load. A prevalence study of cataract has recently been conducted in India at 15 different centres, each covering approximately a population of 4,000. A manual of procedures for conducting cataract prevalence studies had been prepared, tested and used for this study. These procedures were specifically adopted, keeping in view the constraints of manpower, equipment etc., and the usual community response and lack of cooperation for detailed check-ups during surveys.

Adult↗
PubMed2005

Humanitarian Use Devices/Humanitarian Device Exemptions in cardiovascular medicine.

The Second Dartmouth Device Development Symposium held in October 2004 brought together leaders from the medical device community, including clinical investigators, senior representatives from the US Food and Drug Administration, large and small device manufacturers, and representatives from the financial community to examine difficult issues confronting device development. The role of the Humanitarian Use Device/Humanitarian Device Exemption (HUD/HDE) pathway in the development of new cardiovascular devices was discussed in this forum. The HUD/HDE pathway was created by Congress to facilitate the availability of medical devices for "orphan" indications, ie, those affecting <4000 individuals within the United States each year. The HUD/HDE pathway streamlines the approval process and permits less well-characterized devices to enter the market. HDE approval focuses primarily on issues of safety and scientific soundness and does not require demonstration of efficacy. In the 7 years since the first device was approved in 1997, a total of 35 HDEs have been granted (23 devices, 6 diagnostic tests). As the costs to gain regulatory approval for commonly used devices increase, companies often seek alternative ways to gain market access, including the HUD/HDE pathway. For a given device, there may be multiple legitimate and distinct indications, including indications that meet the HUD criteria. Companies must choose how and when to pursue each of these indications. The consensus of symposium participants was for the HUD/HDE pathway to be reserved for true orphan indications and not be viewed strategically as part of the clinical development plan to access a large market.

Altruism↗
PubMed1981

Measuring the relationship of public psychiatric admissions to rising unemployment.

The results of a correlational analysis of the relationship between monthly state unemployment statistics and admissions to eight Missouri Department of Mental Health facilities are presented. Over a period of 100 months, readmissions, rather than new admissions, showed the strongest positive relationship to unemployment. A second study-a retrospective analysis of admissions before and after a major increase in unemployment-supported the results of the correlational analysis. A third analysis of subset of the original sample, comprised of patients unemployed at the time of admission, suggests that public facilities are more accessible to the unemployed during times of economic adversity. The findings on the relationship of readmission rates to the state of the economy have important implications for policy on deinstitutionalization. The planning, development, and evaluation of community care programs should include consideration of employment data.

Deinstitutionalization↗
PubMed2002

Advanced science education in the regulatory arena: the Center for Drug Evaluation and Research Experience at the Food and Drug Administration.

A challenge faced by the Center for Drug Evaluation and Research (CDER) in effectively carrying out its mission requires it to integrate the disciplines of science, medicine, law, and public policy. One way to do that is by ensuring a highly trained multidisciplinary staff. The CDER has been able to meet this requirement by identifying the core competencies needed to accomplish its mission. The use of a competency-based training model in the planning, development, and delivery of its advanced scientific education program allows CDER staff to maintain current knowledge as well as prepare for future scientific education needs. The CDER educational model could be readily adapted to meet the educational needs of other organizations.

Biological Science Disciplines↗
PubMed2006

Behavioral treatments for pediatric feeding disorders.

The effectiveness of behavioral interventions for pediatric feedings problems has been well documented. However, the application of these procedures in the real world is often more complex and difficult than research reports reveal. Multiple factors such as the child's medical condition and history, medical monitoring requirements, and the need to adjust treatment procedures as intervention progresses make it difficult to follow the best-laid plans developed from reading structured and highly controlled experimental applications. This article details factors to be considered in the actual clinical-based application of behavioral procedures in the treatment of pediatric feeding problems. A description of how referrals are generated and initial assessment is conducted, and a model for inpatient treatment is presented. In addition, the need for efficient and effective treatment in the real world is stressed.

Behavior Therapy↗
PubMed1987

Health promotion and industry. Where interdisciplinary research meets reality.

Health promotion and disease prevention programs are now a common part of worksite life. Their acceptance has been based more on faith than scientific evidence of their effectiveness or benefit to either the companies or the participants. Evaluation research in worksite health promotion offers an opportunity to test the effectiveness of the programs and should be done using the methods of several disciplines: organizational psychology, industrial hygiene, and health education. Because of the inherent difficulties in planning, developing goals and objectives, and measuring outputs in worksite health promotion programs, any effective evaluation will have to combine methods and approaches from each of these perspectives.

Evaluation Studies as Topic↗
PubMed2005

Sustainable waste management in the Indian mining industry.

One of the important sectors that contribute to the national economy is the mining sector. During the mining of minerals and ores, waste materials in the form of overburden are generated. As these are not useful to the mine owners, they may be inappropriately disposed of into the environment, posing serious threat to the environment in the form of land degradation, water and air pollution. The present paper discusses the existing status of waste generation, its characteristics and the disposal methods being adopted in India. Impacts associated with waste disposal practices together with preventive measures for waste disposal are also discussed. Finally, strategies for improvements in existing waste management and for incorporating the same in the overall development plan for the mines are suggested.

Coal↗
PubMed1990

A model for reducing the cost of care in VA medical centers that offer adult day health care.

One approach to providing cost-effective adult day health care (ADHC) services is to guide both the inputs to ADHC services and the provision of other services so that substitution for institutional services can realistically take place. This approach has been used in a randomized clinical trial to evaluate the medical efficacy and cost of ADHC in the Department of Veterans Affairs (DVA). This article describes the strategies that were used to improve the cost effectiveness of ADHC during the evaluation. Cost and use estimates were developed based on the best data available from the DVA and previous research on the cost for patients' use of ADHC, nursing home, hospital, and ambulatory care. A cost workshop was attended by the ADHC managers to develop plans for controlling costs. Plans were identified that increase the likelihood that ADHC can be shown to be less costly than customary care.

Adult↗
PubMedDate not supplied

Home pediatric compassionate extubation: bridging intensive and palliative care.

Compassionate home extubation for pediatric patients is a topic that seldom appears in the literature and is of unknown clinical importance. However, standards in pediatric intensive care unit (PICU) and among pediatric critical care physicians regarding end-of-life decisions are changing, including where and when patient extubation occurs. The authors' hospice recently consulted on an infant with spinal muscular atrophy in the PICU requiring mechanical ventilation, for whom further life-sustaining care was deemed futile. In consultation with the family, nursing staff, physicians, and the ethics committee, and following protocol guidelines, arrangements were made for this infant and his parents to be transported home. Once comfortable with his family, a small amount of lorazepam was given and the endotracheal tube removed. The infant died quietly about 20 minutes later. This case prompted the authors to review the current state of published articles covering this topic, suggest a protocol for implementing home extubation, realize imposed barriers, and discuss potential solutions. A well-developed plan for home extubation procedures may improve interactions with PICU and hospice services and at the same time provide additional choices for parents and patients wishing to maximize end-of-life quality outside the hospital setting.

Decision Making↗
PubMedDate not supplied

Treatment fidelity plan for an activity intervention designed for persons with dementia.

The testing of psychosocial interventions in a clinical trial poses many challenges to maintaining a rigorous experimental protocol and to delivering the interventions uniformly throughout the project. These challenges directly affect the reported effectiveness of psychosocial interventions. In this article, the authors describe the treatment fidelity plan developed by an interdisciplinary research team from recreational therapy and nursing for implementing recreational activities during a clinical trial funded by the National Institute of Nursing Research. The trial tests the efficacy of activities for responding to the behavioral symptoms of dementia. The authors report treatment fidelity strategies to allow comparison of their intervention with that of other studies, to improve effect size in similar studies, and to facilitate replication and translation of this work into clinical practice.

Dementia↗
PubMed2005

The health workforce crisis in TB control: a report from high-burden countries.

BACKGROUND: Human resources (HR) constraints have been reported as one of the main barriers to achieving the 2005 global tuberculosis (TB) control targets in 18 of the 22 TB high-burden countries (HBCs); consequently we try to assess the current HR available for TB control in HBCs. METHODS: A standard questionnaire designed to collect information on staff numbers, skills, training activities and current staff shortages at different health service levels was sent to national TB control programme managers in all HBCs. RESULTS: Nineteen HBCs (86%) replied, and 17 (77%) followed the questionnaire format to provide data. Complete information on staff numbers at all service levels was available from nine countries and data on skill levels and training were complete in six countries. Data showed considerable variations in staff numbers, proportions of trained staff, length of courses and quality of training activities. Eleven HBCs had developed training materials, many used implementation guidelines for training and only three used participatory educational methods. Two countries reported shortages of staff at district health facility level, whereas 14 reported shortages at central level. There was no apparent association between reported staff numbers (and skills) and the country's TB burden or current case detection rates (CDR). CONCLUSION: There were few readily available data on HR for TB control in HBCs, particularly in the larger ones. The great variations in staff numbers and the poor association between information on workforce, proportion of trained staff, and length and quality of courses suggested a lack of valid information and/or poor data reliability. There is urgent need to support HBCs to develop a comprehensive HR strategy involving short-term and long-term HR development plans and strengthening their HR planning and management capabilities.

Journal Article↗
PubMed2006

Fatigue Intervention by Nurses Evaluation--the FINE Trial. A randomised controlled trial of nurse led self-help treatment for patients in primary care with chronic fatigue syndrome: study protocol. [ISRCTN74156610].

BACKGROUND: Chronic fatigue syndrome, also known as ME (CFS/ME), is a condition characterised primarily by severe, disabling fatigue, of unknown origin, which has a poor prognosis and serious personal and economic consequences. Evidence for the effectiveness of any treatment for CFS/ME in primary care, where most patients are seen, is sparse. Recently, a brief, pragmatic treatment for CFS/ME, based on a physiological dysregulation model of the condition, was shown to be successful in improving fatigue and physical functioning in patients in secondary care. The treatment involves providing patients with a readily understandable explanation of their symptoms, from which flows the rationale for a graded rehabilitative plan, developed collaboratively with the therapist. The present trial will test the effectiveness and cost-effectiveness of pragmatic rehabilitation when delivered by specially trained general nurses in primary care. We selected a client-centred counselling intervention, called supportive listening, as a comparison treatment. Counselling has been shown to be as effective as cognitive behaviour therapy for treating fatigue in primary care, is more readily available, and controls for supportive therapist contact time. Our control condition is treatment as usual by the general practitioner (GP). METHODS AND DESIGN: This study protocol describes the design of an ongoing, single-blind, pragmatic randomized controlled trial of a brief (18 week) self-help treatment, pragmatic rehabilitation, delivered by specially trained nurse-therapists in patients' homes, compared with nurse-therapist delivered supportive listening and treatment as usual by the GP. An economic evaluation, taking a societal viewpoint, is being carried out alongside the clinical trial. Three adult general nurses were trained over a six month period to deliver the two interventions. Patients aged over 18 and fulfilling the Oxford criteria for CFS are assessed at baseline, after the intervention, and again one year later. Primary outcomes are self-reported physical functioning and fatigue at one year, and will be analysed on an intention-to-treat basis. A qualitative study will examine the interventions' mechanisms of change, and also GPs' drivers and barriers towards referral.

Clinical Protocols↗
PubMed2006

Adoption and sustainability of decision support for patients facing health decisions: an implementation case study in nursing.

BACKGROUND: Effective interventions prepare patients for making values-sensitive health decisions by helping them become informed and clarifying their values for each of the options. However, patient decision support interventions have not been widely implemented and little is known about effective models for delivering them to patients. The purpose of this study was to describe call centre nurses' adoption of a decision support protocol into practice following exposure to an implementation intervention and to identify factors influencing sustainable nursing practice changes. METHODS: Exploratory case study at a Canadian province-wide call centre guided by the Ottawa Model of Research Use. Data sources included a survey of nurses who participated in an implementation intervention (n = 31), 2 focus groups with nurses, interviews with 4 administrators, and a document review. RESULTS: Twenty-five of 31 nurses responded to the survey measuring adoption of decision support in practice. Of the 25 nurses, 11 had used the decision support protocol in their practice within one month of the intervention. Twenty-two of the 25 intended to use it within the next three months. Although some nurses found it challenging to begin using the protocol, most nurses reported that it: a) helped them recognize callers needing decision support; b) changed their approach to handling these calls; and c) was a positive enhancement to their practice. Strategies identified to promote sustainability of practice changes included integration of the decision support protocol in the call centre database, streamlining the patient decision aids for easier use via telephone, clarifying the administrative direction for the call centre's program, creating a call length guideline specific for these calls, incorporating decision support training in the staff development plan, and informing the public of this enhanced service. CONCLUSION: Although most nurses adopted the decision support protocol for coaching callers facing values-sensitive decisions, to sustain practice changes, interventions are required to manage barriers in the practice environment and integrate decision support into the organization's policies, resources, and routine activities.

Journal Article↗