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This brief commentary offers one reader's reactions to the ideas advanced by Huerta, Casebeer and VanderPlaat. I highlight the need for further elucidation of the construct, make suggestions to deal with some of identified paradoxes and build on the ideas for future development.
A standardized curriculum in emergency and disaster medical response for use in the former Soviet Union was implemented under an American International Health Alliance partnership program involving over 60 healthcare and educational institutions in the United States and the Commonwealth of Independent States. The core curriculum was based on U.S. standards and developed in collaboration with local faculty to address emergency and disaster medical needs specific to the region. Local faculty members were trained by U.S. partners using a train-the-trainers methodology at U.S. partner institutions. This partnership program led to the development of 16 regional training centers in 11 countries over an 8-year period. Over 39,000 healthcare workers and first responders have now been trained throughout this network of regional training centers. Wide dissemination of standardized training encourages uniform delivery of medical care within regions and may facilitate provision of mutual aid between regional jurisdictions.
After decades of decline in developed countries, there was a resurgence of tuberculosis in the mid-1980s accompanied by increased recognition that this infectious disease has long remained a major public health problem at the global level. New methods from molecular biology, in particular DNA 'fingerprinting' (of Mycobacterium tuberculosis), made it clear that current transmission and recent infection (in contrast to reactivation of earlier, latent infection) were much more significant than previously believed. Studies of tuberculosis outbreaks using these new tools pointed to complex networks through which infection was spreading and highlighted the need for new approaches to outbreak investigation and disease control. In the study reported here a new approach--combining methods from molecular biology, epidemiology and network analysis--was used to examine an outbreak of tuberculosis in Houston, Texas. Initial investigation using conventional strategies revealed few contacts among 37 patients with identical (six-band) DNA (IS6110-based) fingerprints but subsequent research uncovered over 40 places (including many gay bars) to which patients in this outbreak could be linked. Network methods were used to reconstruct an outbreak network and to quantify the relative importance (here, 'betweenness' centrality) of different actors (persons and places) playing a role in the outbreak. The multidisciplinary work provides the basis for a new approach to outbreak investigation and disease control.
Seven evaluation studies of American Cancer Society programs offer findings useful for improving the programs studied and have larger implications for public health initiatives that rely on volunteers, the training of trainers, professional referral agents, and outreach through faith organizations or other indigenous community groups. Studies documented the following, for example: higher levels of productivity among volunteers who are cancer survivors, have health-related backgrounds, have college degrees, or both; the value of using existing organizations to recruit volunteers; the need for improved selection methods to reduce attrition in programs using "train the trainer" models; and the outreach potential of faith organizations as nodes in social networks within communities. The studies demonstrate to all voluntary health organizations the importance of assembling an accurate database to describe their activities and to enable them to answer important management questions. Lessons from these studies also can contribute to the development of better methods for the study of public health programs and for the incorporation of evaluation into the process of continuous program improvement within voluntary health organizations.
It is increasingly common in Hong Kong and elsewhere for employers to contract directly with physician networks to provide medical services to employees. These contracts are known in Hong Kong as contract medicine arrangements. In other countries and areas, managed care organizations are generally required by regulation or legislation to ensure that services of adequate quality are provided to patients who are locked in to network providers. There are no such requirements in Hong Kong and concerns have been raised about potential quality and cost trade-offs in contract medicine arrangements. Satisfaction surveys were sent to contract medicine enrollees in one large company in Hong Kong. The response rate was 30% and analysis of non-respondent data shows that respondents were representative of their group. Comparison of satisfaction using logistic regression showed that risk-bearing networks paid by capitation had consistently lower satisfaction ratings across all major dimensions including access, interpersonal care, communication with the doctor, choice of doctor, and outcomes. These findings suggest that quality, at least as perceived by the patient, may be lower in these networks. The issue is of concern in Asia where infrastructures and data systems are not well developed to adequately monitor quality of care or protect patient interests. This study highlights the need to structure pre-paid provider networks and managed care organizations so that quality of care is not compromised. At a time when managed care concepts are being applied throughout Asia, we believe attention needs to be drawn to this problem.
This article discusses the role of patients and their families as peer support providers to other patients, and as decision makers within organizations. We use as a model the Bayview Support Network, a self-help network at the Toronto-Sunnybrook Regional Cancer Centre. We review the benefits of partnership, costs, limitations and risks. A list of features that contribute to effective partnership is also provided.
The extent of hospital involvement in integrated delivery systems (IDSs) during 1996 was assessed by a national sample of 235 short-term private general hospitals. Two out of five hospitals were participating in networks with some financial risk sharing, and another third reported membership in IDS networks without financial obligations. Managed care's presence was the only significant factor moving hospitals from a stand-alone status to network membership. The decision to share financial risk was influenced not only by managed care pressures, but also by the level of local hospital competition and the severity of the inpatient case mix.
In 1995, with support from the Fogarty International Center of the National Institutes of Health, The Center for International Rural and Environmental Health (CIREH) at The University of Iowa began developing the multi-level International Training and Research Program in Occupational and Environmental Health, focusing on countries in Central and Eastern Europe that were formerly under socialist control and have particular occupational and environmental health needs after decades of neglect and mismanagement. The purpose of the program is to prepare health science professionals to return to their home countries with new skills, added confidence, and leadership capabilities in public health to lead their colleagues and institutions in meeting the needs in their respective countries and establish active national and international networks and collaborations. By December 1998, 19 trainees had completed the five-month program and returned home to conduct workshops for others in their countries. Details of the program are presented.
Primary care networks can play a pivotal role in the delivery of healthcare services and are much sought after by integrated delivery systems that are attempting to attract managed care contracts. However, not all primary care networks are attractive prospects for affiliation; some lack the ingredients for financial success that integrated delivery systems require. A primary care network can ensure its financial soundness and thereby become an attractive candidate for affiliation by meeting the requirements of effective networks. These requirements include reaching consensus on the role the network will play in the delivery system, consolidating network practice sites, paying justifiable practice acquisition prices, using nonphysician practitioners appropriately, assuming risk, offering physicians participation packages, providing incentive compensation plans, implementing integrated information technology, securing multiple payer contracts, and implementing quality assurance standards.
Within the Rubis 4th framework of European project is led a pilot experiment of tools and services for health professionals in prospect for the Aquitanian healthcare network. The sarcoma group of the FNCLCC (47 people) uses on its web site a multidisciplinary dialogue with a specific discussion forum. This service allows the anonymous publication of a imaging clinical case and to start a take care discussion. 87 cases were published in 13 months involving 261 answers from February 1999 to February 2000. A case is published every 4 days on average and the deadlines for replies regularly drop (15 days in February 1999 down 1.1 day in February 2000). The cases are published either for a diagnosis or treatment request (30%) or for the physical preparation of meeting or for the continuous medical training (70%). There are many advantages in comparison with the other possibilities of discussion: availability, autonomy of publication, cost, number of experts participating. These NTIC services will be developing within the regional healthcare oncology networks and are already tested by other regional groups (Lymphoma) considering the simplicity of use, management and training of the functionality.
Tayside diabetes network includes an advanced patient auditing system which highlights risks. The clinical governance peer support system is designed to help GP practices hit targets. Diabetes resource centres have helped the area achieve a one to two week wait for insulin initiation.
A nostalgia theme was fully explored by Eastern Connecticut Health Network (ECHN), Manchester, Conn., in its celebration of Cancer Survivors Day, June 6. The observance is sponsored by the national Cancer Survivors Day organization. This year more than 700 facilities across the country observed the occasion.
Minnesota's 1994 health care reform legislation authorized the establishment of community integrated service networks (CISNs) and health care provider cooperatives, which were envisioned as new health care delivery models that could be successfully implemented in rural areas of the state. Four CISNs are licensed, and three organizations are incorporated as health care provider cooperatives. Many of the policy issues Minnesota has faced regarding the development of CISNs and health care provider cooperatives in rural areas are similar to those raised by current Medicare reform proposals.
The groundwork for the Pacific Islander cancer control network (PICCN) began in the early 1990s with a study of the cancer control needs of American Samoans. The necessity for similar studies among other Pacific Islander populations led to the development of PICCN. The project's principal objectives were to increase cancer awareness and to enhance cancer control research among American Samoans, Tongans, and Chamorros. PICCN was organized around a steering committee and 6 community advisory boards, 2 from each of the targeted populations. Membership included community leaders, cancer control experts, and various academic and technical organizations involved with cancer control. Through this infrastructure, the investigators developed new culturally sensitive cancer education materials and distributed them in a culturally appropriate manner. They also initiated a cancer control research training program, educated Pacific Islander students in this field, and conducted pilot research projects. PICCN conducted nearly 200 cancer awareness activities in its 6 study sites and developed cancer educational materials on prostate, colorectal, lung, breast, and cervical cancer and tobacco control in the Samoan, Tongan, and Chamorro languages. PICCN trained 9 students who conducted 7 pilot research projects designed to answer important questions regarding the cancer control needs of Pacific Islanders and to inform interventions targeting those needs. The legacy of PICCN lies in its advancement of improving cancer control among Pacific Islanders and setting the stage for interventions that will help to eliminate cancer-related health disparities. Cancer 2006. (c) 2006 American Cancer Society.
Debates about the relative advantages of health systems versus more loosely structured health networks have largely ignored issues of how these different organizational forms are governed. Based on comparisons of two large samples of health systems and health networks, our findings indicate that the majority of both types of organized delivery systems have governing bodies separate from those of affiliate organizations, high proportional representation by affiliate organizations, and similar board size.
The city of Sao Paulo is located in the center of a metropolitan area with nearly 18 million inhabitants and 300,000 births/year. The currently existing medical genetics services are unable to meet the demand, due to their insufficient physical and personnel infrastructure. Institutions and experts in medical genetics could give short training and refresher courses to health professionals to enable them to work in the public health network. The city has a reasonably well developed health care network, represented by the Single Health System (Sistema Unico de Saude - SUS) and by the Family Health Program (Programa de Saude da Familia - PSF). The financial resources for such actions originate in the budget of the managing agencies of such systems. The limitations of genetic services provided to the population of the city could be overcome in a short period of time by developing programs within the public health care network. The city has institutions, professionals and financial resources to make this project feasible. To that end, the competent authorities of the Sao Paulo State and City Secretariats of Health should take managerial responsibility for the genetic services in the city.
We aimed to relate dynamic changes in risk-network (sex and/or injecting drug) structure to observe STD/HIV transmission. We analysed macro- and micro-structural elements in 2 heterosexual networks, augmented by ethnographic observations. In a Colorado cohort of injecting drug users (n = 595), measures of subgroup formation and of density of activity show decrease of network cohesion over time; only one HIV transmission was observed in 3 years. In a group of adolescent heterosexuals in Georgia (n = 99), the reverse process (increase in structural cohesion) was associated with efficient syphilis transmission: 10 cases were observed. Changes in personal risk behaviours over time were modest. STD/HIV transmission patterns were associated with intensification or diminution of network cohesion. Network and ethnographic data suggest that enhanced connectivity facilitates transmission while segmentation impedes it, suggesting opportunities for interventions. These data also emphasize the need to re-evaluate purely behavioural explanations of STD/HIV transmission.
This paper examines social networks and social support among poor elderly ill in Guadalajara, Mexico. We interviewed 40 hospitalized elderly patients. The mean size of social networks was 7.5, basically involving women, multiple generations, and members of the extended family. Emotional support was more frequent than other types of social support. Elderly women had larger social networks and received more social support than men. Married elderly also had larger social networks and more social support than single patients. There were no differences between age and living arrangements with social networks and social support. Future studies are needed on the social and cultural environment of social support for the elderly.