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PubMed1994

Necessity to improve common understanding about the security issues among hospitals in Japan and some feasible approaches.

To improve common understanding about security issues, the importance of classifying the information is stressed, after describing briefly the social background concerning privacy-related problems in Japan. We discuss here the classification only from the following two points of view: (a) the ownership; and (b) how to use. We will derive a two-dimensional fuzzy membership function to describe the ownership and a 'how to use' three-dimensional one as models for describing the framework concerning access right and informed consent.

Computer Security↗
PubMed1993

Cats and toxoplasmosis risk in HIV-infected adults.

OBJECTIVE: To establish the prevalence and incidence of toxoplasmosis in an adult human immunodeficiency virus (HIV) population, and to determine if cat ownership contributes to the risk of toxoplasmosis. DESIGN: Retrospective record and laboratory review, coupled with a patient survey. SETTING: A tertiary-care military hospital HIV program. PATIENTS: A total of 723 HIV-infected adults, all former or current US military personnel. MAIN OUTCOME MEASURES: Prevalence and incidence of serologic evidence of toxoplasmosis infection. RESULTS: A total of 723 HIV-infected patients had serial Toxoplasma IgG antibody determinations. Seventy patients (9.7%) were positive on their initial screen; the seronegative patients were tested annually for 1 to 5 years (mean duration of follow-up, 2.1 years). Only 13 patients (2.0%) who were initially seronegative acquired antibodies to Toxoplasma gondii. None of the patients who seroconverted developed clinical disease. A pet history was available on 12 of 13 patients who seroconverted; only one (8.3%) had owned or lived in a household with a cat during the period of seroconversion. The calculated attributable risk of cat ownership/exposure for toxoplasmosis seroconversion in this population is -2.9 per 100 persons annually. CONCLUSION: Toxoplasma antibody seroconversion in an adult HIV-infected population is unusual and appears unrelated to cat ownership or exposure.

AIDS-Related Opportunistic Infections↗
PubMed1996

An etiologic study of Paget's disease.

The objective of this case-control questionnaire study was to determine whether a history of measles or of dog ownership occurred with different frequencies in Paget's disease patients and in age- and sex-matched controls. Clustering of Paget's disease cases in geographic foci was also looked for, as well as a difference in the prevalence of Paget's disease according to whether the subsoil was composed of rocks from the primary or the tertiary-quaternary geologic periods. Completed questionnaires were obtained from 247 Paget's disease patients and 281 controls. Paget's disease was significantly associated with a history of measles (odds ratio, 2.46) but not with a history of mumps (odds ratio, 0.79) or with dog ownership (odds ratio, 0.97). The 174 cases of Paget's disease in subjects from the study district were distributed throughout the district, with no geographic clustering. This result was confirmed by the analysis of the ratios of Paget's disease cases over the total population in each county in the study district. The incidence of Paget's disease was slightly higher in areas with a primary subsoil, but the difference was not statistically significant (chi-square, 0.79; P = 0.37).

Aged↗
PubMed1996

Medical records and access thereto.

Medical records are essential tools in the practice of medicine. They are important in the planning and monitoring of patient care and for the protection of the legal interests of patients, hospitals and doctors. There is a legal duty on doctors to maintain confidentiality and failure to do so may result in an action for invasion of privacy, defamation or even breach of contract. There are, however, exceptions to this rule. There are procedural remedies available to obtain access to medical records where they are relevant to civil or criminal proceedings. There are also constitutional provisions under the Interim and Working Draft Constitutions which may allow such access. The former only applies to records held by the state while the latter applies to both state and privately held records. Ownership of medical records usually vests in the doctor or institution treating the patient, but such ownership is custodial rather than absolute. Patient records should be accurate, objective and contemporaneous. The international trend is to allow patients to inspect their records and to allow them to make copies thereof. It is submitted that given the provisions of the Interim and Working Draft Constitutions the same should apply in South Africa.

Confidentiality↗
PubMed1997

Hospital and ambulatory surgery center syndications: selling interests to physicians.

Physician ownership in hospitals and ambulatory surgery centers remains a relatively surefire method of protecting a portion of a facility's revenues. Implementation of a plan to broaden physician ownership requires compliance with legal and regulatory schemes. This article discusses the prototypical business terms of such transactions, outlines the process for completing such syndications, and analyzes the legal statutes that must be complied with in implementing the effort.

Fraud↗
PubMed1997

Epilepsy and the law-medical records.

This paper reviews the need to keep medical records and concludes that Section 126 of the New South Wales Medical Practice Act, 1992, requires such provision to comply with adequate "professional conduct". This was above and beyond other possible mandatory maintenance of appropriate records, such as may be covered by the notifiable diseases provisions of the Public Health Act. Ethical codes of conduct imposed further obligations to maintain appropriate records, and legal defence against claims of misconduct or negligence required documented evidence to refute false accusations. The emphasis of records has changed with greater need to stipulate risk exposure associated with proposed treatments and advice provided for such things as necessary follow-up. It was further shown that appointment diaries, extra file entries and indications of any failed attendance and resultant subsequent actions were all part of adequate record-keeping. Finally, the paper reviews ownership of medical records and refers to the New South Wales case of Ms Breen, in which it was found that ownership of records, as at the printing of this paper, resided with the doctor.

Disease Notification↗
PubMed1998

Advance care planning in nursing homes: pre- and post-Patient Self-Determination Act.

OBJECTIVES: (1) To identify resident and organizational factors associated with the use of advance care plans pre- and post-implementation of the Patient Self-Determination Act (PSDA), and (2) to identify changes (pre- and post-implementation of the PSDA) in the relationship between these factors and the use of advance care plans. DESIGN: Complex, multistage cluster sampling. SETTING: Ten states were selected for variation in geographic location, Medicaid reimbursement rate, and average staffing patterns. Participants were 4,215 nursing home residents in 268 facilities. PRINCIPAL FINDINGS: Seventeen resident and organizational factors were associated with the use of do-not-resuscitate (DNR) orders in 1990, and 12 resident and organizational factors were associated with their use in 1993. Five factors showed a significant change from 1990 to 1993: activities of daily living (ADL) scores, race, cognitive performance scale (CPS) scores, full-time equivalent (FTE) nurse aides per resident, and bed size. Ten resident and organizational factors were associated with use of do-not-hospitalize (DNH) orders in 1990 and six resident and organizational factors were associated with DNH orders in 1993. Four factors showed a significant change from 1990 to 1993: legal guardian, FTE LPNs per resident, Medicaid census, and forprofit ownership. Five resident and organizational factors were associated with the use of living wills in 1990 and seven resident and organizational factors were associated with the use of living wills in 1993. Four factors showed a significant change from 1990 to 1993: ADL scores, race, length of stay, and for-profit ownership. CONCLUSION: The results indicate that the PSDA may have been successful in increasing the use of advance care plans and in changing the types of residents who use advance care plans. However, they also show that the use of advance care plans is associated with organizational characteristics, indicating that some types of facilities may be more willing and able to address the PSDA mandates.

Activities of Daily Living↗
PubMed1999

Quality of care in investor-owned vs not-for-profit HMOs.

CONTEXT: The proportion of health maintenance organization (HMO) members enrolled in investor-owned plans has increased sharply, yet little is known about the quality of these plans compared with not-for-profit HMOs. OBJECTIVE: To compare quality-of-care measures for investor-owned and not-for-profit HMOs. DESIGN, SETTING, AND PARTICIPANTS: Analysis of the Health Plan Employer Data and Information Set (HEDIS) Version 3.0 from the National Committee for Quality Assurance's Quality Compass 1997, which included 1996 quality-of-care data for 329 HMO plans (248 investor-owned and 81 not-for-profit), representing 56% of the total HMO enrollment in the United States. MAIN OUTCOME MEASURES: Rates for 14 HEDIS quality-of-care indicators. RESULTS: Compared with not-for-profit HMOs, investor-owned plans had lower rates for all 14 quality-of-care indicators. Among patients discharged from the hospital after myocardial infarction, 59.2% of members in investor-owned HMOs vs 70.6% in not-for-profit plans received a beta-blocker (P<.001); 35.1% of patients with diabetes mellitus in investor-owned plans vs 47.9% in not-for-profit plans had annual eye examinations (P<.001). Investor-owned plans had lower rates than not-for-profit plans of immunization (63.9% vs 72.3%; P<.001), mammography (69.4% vs 75.1%; P<.001), Papanicolaou tests (69.2% vs 77.1%; P<.001), and psychiatric hospitalization (70.5% vs 77.1%; P<.001). Quality scores were highest for staff- and group-model HMOs. In multivariate analyses, investor ownership was consistently associated with lower quality after controlling for model type, geographic region, and the method each HMO used to collect data. CONCLUSIONS: Investor-owned HMOs deliver lower quality of care than not-for-profit plans.

Health Facilities, Proprietary↗
PubMedDate not supplied

Output efficiency of health maintenance organizations in Florida.

We use data envelopment analysis (DEA) to measure the relative technical efficiencies of 28 HMOs licensed to practice in the State of Florida in the autumn of 1994. Health care output measures used in the analysis are number of commercial, Medicare and Medicaid members enrolled in each plan. Inputs to the model are capital assets, total expenditures on the provision of medical services and administrative expenses. We find differences in HMO efficiency scores and loss ratios (defined as the ratio of expenses on the provision of medical services to the total expenses incurred by the organization) across individual plans. Differences in efficiency measures across model type (staff, IPA, combination) and ownership types (for-profit, not-for-profit) are small but significant: staff models and for-profits are more efficient. In a multivariate model, we also find that large HMOs are more efficient and HMOs with Medicaid patients are significantly less efficient than other HMOs.

Ambulatory Care↗
PubMed2001

Organization development strategies for continuing medical education.

BACKGROUND: The purpose of this study was to identify organizational strategies for improving staff performance in primary care practices. The study rationale was based on theory, research, and practice regarding educational interventions that help people help themselves. Analysis of qualitative and quantitative data produced both plausible explanations of organizational change and implications for future efforts. METHODS: The Health Education and Research Trial (HEART) Project was an experimental study designed to improve prevention services for cardiovascular disease. Primary care clinics were randomized into four experimental treatments. Two representative practices from each treatment arm were chosen for an in-depth cross-case analysis. Extensive data from each selected practice included patient medical record reviews and questionnaires, interviews and questionnaires from physicians and clinic staff, project records, and follow-up interviews. After detailed case descriptions were created for each practice, a cross-case analysis was performed. RESULTS: Each practice improved cardiovascular prevention services somewhat. However, there was a great range of impact, likely reflecting both experimental intervention and local contingencies. Eight positive influences were identified: effective leadership, priority setting, joint planning, cooperation and teamwork, acquisition of resources, increased support and ownership, accomplishment of improvements, and personal changes. Major influences that hindered improvement included patient load, turmoil related to reorganization, lack of wide-spread routines, hospital-affiliated practice, poor communication, and fragmentation within a clinic. FINDINGS: Continuing medical education providers can enhance preventive services to improve patient health status by promoting organizational change. Suggested strategies supported by this study include selecting able leaders, focusing on accomplishments, obtaining agreement on prevention priorities, addressing local contingencies, increasing teamwork, engaging in joint planning, emphasizing quality improvement, acquiring resources, encouraging persistence, and reducing hindrances.

Cardiovascular Diseases↗
PubMed1993

Have procompetitive changes altered hospital provision of indigent care?

In the past decade alone there have been numerous changes in the financial and competitive environment of hospitals in the United States. Some examples include the advent of Medicare's Prospective Payment System, growth in managed care options, relaxation of states' Certificate of Need (CON) regulations, and court cases questioning the tax-exempt status of nonprofit hospitals. In this paper we attempt to reveal how hospitals alter their provision of care to the poor in a more cost conscious and competitive environment. Using hospital data from the State of California for the fiscal years ending in 1983 and 1987, estimates explaining uncompensated care commitments are presented. In particular, this study illustrates how hospitals under different ownership control varied their provision of uncompensated care over the period studied on average and by profitability level. Other factors, such as hospital location, teaching status, medicare patient load, and contractual adjustments, are also included in the analysis. A number of interesting trends are detected. Moreover, the results are found to be compatible with a quid pro quo hypothesis which states that hospital regulators reward large uncompensated care providers with profitable CON licenses.

California↗
PubMed2001

Cost efficiency of US hospitals: a stochastic frontier approach.

This study examined the impact of managed care and other environmental factors on hospital inefficiency in 1631 US hospitals during the period 1990-1996. A panel, stochastic frontier regression model was used to estimate inefficiency parameters and inefficiency scores. The results suggest that mean estimated inefficiency decreased by about 28% during the study period. Inefficiency was negatively associated with health maintenance organization (HMO) penetration and industry concentration. It was positively related with Medicare share and for-profit ownership status.

Cost-Benefit Analysis↗
PubMedDate not supplied

Japanese hospitals--culture and competition: a study of ten hospitals.

Japanese health care is characterized by a pluralistic system with a high degree of private producers. Central government regulates the prices and the financing system. All citizens are covered by a mandatory employment-based health insurance operating on a non-profit basis. The consumer has a free choice of physician and hospital. A comparison between Japan, Sweden and some other countries shows significant dissimilarities in the length of stay, number of treatments per hospital bed and year and the staffing of hospitals. About 80 per cent of the hospitals and 94 per cent of the clinics are privately owned. The typical private hospital owned by a physician has less than 100 beds. In this paper, data collected (1992/93) in an empirical study of Japanese hospitals and their leadership is presented. Also discussed are the hospitals' style of management, tools and strategies for competition and competences--personal and formal skills required of the leadership in the hospital. There follows a study of ten hospitals, among which hospital directors and chief physicians were interviewed. Interviews are also made with key persons in the Ministry of Health and Welfare and other organizations in the health care field. The result is also analysed from a cultural perspective--'what kind of impact does the Japanese culture have on the health care organization?' and/or 'what kind of sub-culture is developed in the Japanese hospitals'. Some comparisons are made with Sweden, USA, Canada and Germany. The different roles of the professions in the hospital are included in the study as well as the incentives for different kinds of strategies--specialization, growing in size, investments in new equipment, different kind of ownership and hospitals. Another issue discussed is the attempt to uncover whether there is an implicit distribution of specialties--silent agreements between hospitals, etc.

Economic Competition↗
PubMed1993

The supply of volunteer labor: the case of hospitals.

Little is known about the labor market for volunteers, but even less is known about the supply of volunteers to particular industries. This article examines the supply of volunteer labor to one industry, hospitals, and the choices that volunteers make among hospitals with different ownership attributes. Survey data of volunteers at four hospitals located in Madison, Wisconsin, are used to estimate the importance of a number of factors influencing people's willingness to volunteer at hospitals. We found that job opportunities in the labor market and tax rates affect the supply of volunteers. We also found that volunteers are not indifferent to the type of hospital at which they volunteer; a federal government hospital, a nonprofit state-owned teaching hospital, and other nonprofit hospitals were not perfect substitutes in the eyes of individual volunteers in our study.

Career Choice↗
PubMed1986

Hospital characteristics and the use of computer processing and abstract services. A logistic analysis.

The use of computer processing and abstract services by hospitals is in a state of continuing change. Although many hospitals subscribe to abstract or turnkey systems, others are leaving shared services to set up their own in-house systems. To better understand the relationship between hospital characteristics and the use of computer processing and/or abstract services, data from the AHA 1982 Special Survey on Selected Hospital topic were analyzed using logistic regression analysis. Hospital size, ownership, and region were clearly related to the use of computer processing and/or abstract services for processing discharge data. Teaching status was also related to the use of abstract services, although teaching status hospitals also reported more reliance on in-house computer processing. Hospitals located in SMSAs and belonging to chains reported a higher use of discharge abstract services, and hospitals with higher operating margins were more likely to use abstract services on an "off-line" or batch-processing basis. The significance of these findings and their implications for abstract services are discussed.

Abstracting and Indexing↗
PubMed1995

A Kantian argument in favor of unimpeded access to health care.

The principle that everybody should have access to essential health care is in conflict with the notion that property rights should be respected. The Kantian doctrine of rights is explored in order to solve this conflict. Kant's notion of a legislative will is explained and used to show the inherent limits of the legal terms "property" and "ownership" (it can refer only to things external to subjects and to possible objects of choice). What is internal to the subject is outside of the realm of the legislative will. A law excluding those unable to pay from access to essential health care would not be just. A law granting that access would be just.

Beneficence↗
PubMed1999

Reengineering the picture archiving and communication system (PACS) process for digital imaging networks PACS.

Prior to June 1997, military picture archiving and communications systems (PACS) were planned, procured, and installed with key decisions on the system, equipment, and even funding sources made through a research and development office called Medical Diagnostic Imaging Systems (MDIS). Beginning in June 1997, the Joint Imaging Technology Project Office (JITPO) initiated a collaborative and consultative process for planning and implementing PACS into military treatment facilities through a new Department of Defense (DoD) contract vehicle called digital imaging networks (DIN)-PACS. The JITPO reengineered this process incorporating multiple organizations and politics. The reengineered PACS process administered through the JITPO transformed the decision process and accountability from a single office to a consultative method that increased end-user knowledge, responsibility, and ownership in PACS. The JITPO continues to provide information and services that assist multiple groups and users in rendering PACS planning and implementation decisions. Local site project managers are involved from the outset and this end-user collaboration has made the sometimes difficult transition to PACS an easier and more acceptable process for all involved. Corporately, this process saved DoD sites millions by having PACS plans developed within the government and proposed to vendors second, and then having vendors respond specifically to those plans. The integrity and efficiency of the process have reduced the opportunity for implementing nonstandard systems while sharing resources and reducing wasted government dollars. This presentation will describe the chronology of changes, encountered obstacles, and lessons learned within the reengineering of the PACS process for DIN-PACS.

Administrative Personnel↗
PubMed2002

Cross-boundary cooperation in a watershed context: the sentiments of private forest landowners.

Ecosystem management and sustainable forestry on mixed ownership landscapes will require some level of cross-boundary coordination or management. Oregon's experiment with local, voluntary, collaborative forums, called watershed councils, is one mechanism to foster cross-boundary management. Fifty qualitative, in-depth interviews in three study areas were conducted with nonindustrial private forest (NIPF) landowners, watershed council members, and agency employees to learn how and why landowners participate (or not) on watershed councils. Study areas were located in three different areas of the state to reflect different ecological and organizational settings. Our case study identified three themes-stewardship ethic, property rights amid uncertainty, and action orientation-that were most salient among landowners when deciding to participate in their local watershed council. Other factors related to competing opportunities were also identified. Our results relate to the social psychological antecedents to cooperation of perceived consensus, group identity, and legitimacy of authority as well as to applied situations where cross-boundary coordination and management are goals.

Conservation of Natural Resources↗