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PubMed2004

Ethical issues in participatory action research.

The purpose of this article is to describe the ethical issues arising out of participatory action research (PAR), on the basis of both an empirical study and the research literature, and to discuss how to deal with these issues. The data consist of the experiences and results of three phases of PAR relating to orthopaedic patients with rheumatoid arthritis (RA) and the analysis of 20 articles on the ethics of action research. As a result, the following ethical issues and the ways to treat them were discussed: informed consent, confidentiality and anonymity, protecting an individual from harm, the role of the researcher, the location of 'power' in PAR, and the ownership of the research. The flexibility of PAR in use and its main features are also related to the decisions made and actions taken in response to ethical issues. It is particularly important in PAR to proceed according to the participants, and to involve them from the beginning of the process, in order to insure the equal balance of power between participants and researcher.

Arthritis, Rheumatoid↗
PubMed2004

Cost convergence between public and for-profit hospitals under prospective payment and high competition in Taiwan.

OBJECTIVE: To test the hypotheses that: (1) average adjusted costs per discharge are higher in high-competition relative to low-competition markets, and (2) increased competition is associated with cost convergence between public and for-profit (FP) hospitals for case payment diagnoses, but not for cost-plus reimbursed diagnoses. DATA SOURCES: Taiwan's National Health Insurance database; 325,851 inpatient claims for cesarean section, vaginal delivery, prostatectomy, and thyroidectomy (all case payment), and bronchial asthma and cholelithiasis (both cost-based payment). STUDY DESIGN: Retrospective population-based, cross-sectional study. DATA ANALYSIS: Diagnosis-wise regression analyses were done to explore associations between cost per discharge and hospital ownership under high and low competition, adjusted for clinical severity and institutional characteristics. PRINCIPAL FINDINGS: Adjusted costs per discharge are higher for all diagnoses in high-competition markets. For case payment diagnoses, the magnitudes of adjusted cost differences between public and FP hospitals are lower under high competition relative to low competition. This is not so for the cost-based diagnoses. CONCLUSIONS: We find that the empirical evidence supports both our hypotheses.

Economic Competition↗
PubMed1988

An evaluation of increased mortality rates in Wisconsin nursing homes.

We reviewed mortality data from 80 nonprofit and government-owned skilled nursing facilities (SNFs) to evaluate previously reported increases in deaths occurring in Wisconsin nursing homes since 1983. Comparing nursing home mortality data for 1982 and 1985, we found a 16.6% increase in overall nursing home mortality rates. The increased mortality rates occurred in the sample SNFs regardless of ownership, Medicare certification, bed size, metropolitan area and hospital affiliation. There were two explanations for the increased mortality rates. First, the number of residents dying within 30 days after nursing home admission increased 59%. The majority of these short-lived residents had been discharged from hospitals indicating a transfer of terminally ill patients into nursing homes just prior to death. Second, there was a 27% increase in the mortality rate of residents living in the nursing home for 1 to 5 years suggesting that the population had become sicker between 1982 and 1985. These data reflect both the impact of Medicares Prospective Payment System (PPS) on the study nursing homes and an increase in the severity of illness of Wisconsin's nursing home population between 1982 and 1985. The findings document an increased role for nursing homes in caring for more acutely ill patients since the passage of the PPS, and have implications for nursing home reimbursement policies and quality of care.

Age Factors↗
PubMed1995

Lessons learned from a prospective meta-analysis.

OBJECTIVE: To describe the unique aspects of and the lessons learned in planning and conducting a pooled analysis of multiple trials evaluating interventions to reduce functional decline in hospitalized older persons. Specific examples from the Hospital Outcomes Project for the Elderly (HOPE) meta-analysis are discussed. DESIGN: A prospective meta-analysis (PMA) that compiled and pooled data from concurrently conducted clinical trials testing related but distinct interventions. SETTING: The Data Coordinating Center for the prospective meta-analysis coordinated the collection and analysis of common outcome data from five university-affiliated hospitals and one community hospital conducting the clinical trials. PARTICIPANTS: Acutely ill hospitalized elderly participants at least 65 to 75 years old. INTERVENTIONS: Treatments being evaluated included exercise, physical therapy, a multidisciplinary geriatric care unit, a multidisciplinary in-hospital intervention with post-discharge care, a nursing-based geriatric care program, and a program to improve detection and evaluation of delirious patients. CONCLUSION: The prospective meta-analysis provides selected advantages over independently conducted clinical trials and retrospective meta-analyses. It does, however, pose special design and operational challenges that must be addressed well before initiation of the individual trials. Specific issues of concern include: maintaining scientific integrity of both the individual trials and the PMA; reaching consensus on PMA goals, what data to collect, how and when to collect them and how to maintain uniformly high quality data across all sites; defining the role of the Data Coordinating Center in a multicenter project that utilizes different trials and protocols; and establishing policies concerning analyses of the pooled data, publication of pooled analyses, and ownership of the pooled database.

Aged↗
PubMed2001

Ethics seminars: the practice of medical procedures on newly dead patients--is consent warranted?

The use of the newly dead to teach procedures is widely practiced in training institutions. This model allows a realistic opportunity both to become more familiar with lifesaving maneuvers before they are actually necessary and to maintain proficiency. Whether to notify the next of kin first has been an issue of ethical debate. Some argue a "don't ask, don't tell" policy is justified, while others mandate open consent by family members prior to the practice. Several medical studies have found that patients and families are likely to consent to the procedures but prefer to be asked permission first. Multiple legal cases have addressed the issue of usage of cadavers postmortem without expressed permission. Earlier cases emphasized the concept of "pseudo-property" rights and declared that the next of kin do not have constitutional ownership of the deceased person's body. More recent legal cases are declaring that families do, in fact, possess these rights. In this day and age of increasing recognition of personal autonomy, it is probably prudent to approach the next of kin for permission before performing procedures on the newly deceased.

Attitude to Death↗
PubMed1992

Multihospital system affiliation as a survival strategy for rural hospitals under the prospective payment system.

The introduction of Medicare's Prospective Payment System (PPS) has disproportionately increased financial pressures on rural hospitals and posed challenges to the survival of these institutions. Increasingly, rural hospitals are seeking strategies that can enhance their chances for survival in a turbulent and hostile environment. This study examined the survival effects of one such strategy, multihospital system affiliation. Specifically, we assessed: (1) whether and how different types of system affiliation in the post-PPS era affect the likelihood of rural hospital survival; (2) whether particular structural, environmental and hospital performance characteristics moderate the effects of system affiliation on rural hospital survival; and (3) whether systematic selection by rural hospitals into multihospital systems potentially accounts for observed relationships between system affiliation and survival. Proportional hazards analyses indicate that system affiliation with investor-owned systems significantly reduces survival probabilities of rural hospitals. Affiliation with not-for-profit systems or system affiliation under contract management arrangements does not affect survival probabilities of rural hospitals. These general findings are moderated by the effects of hospital ownership and size at the time of affiliation. Finally, study findings indicated that systematic selection by poor performing rural hospitals into investor-owned systems has occurred in the post-PPS era. No evidence of selection into not-for-profit systems was discovered.

Contract Services↗
PubMed2002

Effect of declining owned-cat population on veterinary practices in Sydney.

OBJECTIVES: To investigate relationships between declining owned-cat populations and cat-related clinical work and practice activities. DESIGN: Sydney practitioners were interviewed, and practice records were examined, from small animal veterinary practices (n = 56) in Sydney. Using data that covered a 4 year period, the age distribution of cats was examined and associated trends in cat-related clinical work were analysed. RESULTS: Important changes in the pet population attending veterinary practices were found, with 38.2% of respondents reporting a fall in cat desexings from 1996 to 2000. CONCLUSIONS: While economic impact could not be determined, the qualitative data demonstrated that the majority of practices in the survey were active in the promotion of cat ownership. The study provides a useful model for future investigations. To facilitate this process and to enhance principals' knowledge of their practice's population dynamics, we advocate a minimum standard of data collection that records week-by-week activities and the deaths of pets.

Animals↗
PubMed2003

Estimated and predicted changes in the cat population of Australian households from 1979 to 2005.

OBJECTIVE: To estimate and predict changes in the cat population of Australian households from 1979 to 2005. METHOD: Telephone surveys were used to estimate Australia's total household cat population for each year from 1979 to 1999. A simple mathematical model based on population characteristics in 1995 was used to predict future population changes to 2005. Estimates and predictions for 1996 to 1999 were compared to validate the model. RESULTS: Australia's household cat population increased steadily from 2.23 million in 1979 to peak at 3.24 million in 1988. Since then it has steadily declined to 2.60 million in 1999. The population size predicted from the mathematical model was similar to that from surveys for the years 1996 to 1999. It is predicted that the population will continue to decline to approximately 2.19 million in 2005. The proportion of Australian households owning cats fell from 31.1% in 1994 to 25.8% in 1999, while the average number of cats per cat-owning household remained relatively constant at 1.47. CONCLUSIONS: Australia's household cat population is decreasing, falling by 19% between 1988, when it reached its peak, and 1999. This contrasts with the US where the population increased by 13.9% over the same period. The decline in Australia appears to be due to a decrease in the total number of cat-owning households rather than the number of cats per cat-owning household. It is likely that this trend will continue unless there is a change in household pet ownership preferences in the meantime.

Animals↗
PubMed1985

Sperm and ova as property.

To whom do sperm and ova belong? Few tissues are produced by the human body with more waste than the germ cells. Yet dominion over the germ cells, and over the early embryo that results from their union in vitro, is behind much of the emotion that modern reproductive intervention can engender. The germ cells differ from other human tissues that can be donated or transplanted because they carry readily utilizable genetic information. Eventual expression of the germ cells' genetic potential is the legitimate concern and responsibility of their donors, although in the right circumstances the responsibility can by agreement be entrusted to institutions administering gamete or embryo donor programmes; these institutions, in turn, may need to assume responsibility for decisions if, in the case of embryo storage, the wishes of the two donors conflict. The fact of sperm and ovum ownership (and the genetic potential that goes with it) before individuals part with these tissues is beyond dispute. Some contentious issues may be clarified if this area of human dominion, namely control over genetic expression among offspring, is acknowledged to be the legitimate persisting concern of those who have produced sperm and ova after storage commences.

Embryo Transfer↗
PubMed1998

Legal, ethical, and social issues in human genome research.

In the past several decades, biological sciences have been revolutionized by their increased understanding of how life works at the molecular level. In what ways, and to what extent, will this scientific revolution affect the human societies within which the science is situated? The legal, ethical, and social implications of research in human genetics have been discussed in depth, particularly in the context of the Human Genome Project and, to a lesser extent, the proposed Human Genome Diversity Project. Both projects could have significant effects on society, the former largely at the level of individuals or families and the latter primarily at the level of ethnic groups or nations. These effects can be grouped in six broad categories: identity, prediction, history, manipulation, ownership and control, and destiny.

DNA↗
PubMed2003

The $1000 genome: ethical and legal issues in whole genome sequencing of individuals.

Progress in gene sequencing could make rapid whole genome sequencing of individuals affordable to millions of persons and useful for many purposes in a future era of genomic medicine. Using the idea of $1000 genome as a focus, this article reviews the main technical, ethical, and legal issues that must be resolved to make mass genotyping of individuals cost-effective and ethically effective. It presents the case for individual ownership of a person's genome and its formation, and shows the implications of that position for rights to informed consent and privacy over sequencing, testing, and disclosing genomic information about identifiable individuals. Legal recognition of a person's right to control his or her genome and the information that it contains is essential for further progress in applying genomic discoveries to human lives.

Adult↗
PubMed1988

Privatization of psychiatric services.

The authors provide an overview of privatization, a major trend in mental health policy, focusing in particular on the reasons for and consequences of substantial growth and change in ownership of private psychiatric hospitals; the proportion of all nonfederal psychiatric inpatient beds in private facilities has increased from less than 10% in 1970 to 35% today. It is estimated that between 1970 and 1986, the proportion of total nonfederal psychiatric inpatient beds in the United States that were under corporate for-profit auspices increased from about 1% to 15%. The authors distinguish and examine several aspects of privatization and assess the implications of these changes for psychiatry and for public policy and research.

Economics, Hospital↗
PubMed2004

Designing and managing public housing self-sufficiency programs: the Youngs Lake Commons Program.

This article evaluates an experimental public housing self-sufficiency program that encourages home ownership among low-income families. A quasi-experimental design, in combination with focus groups, records review, and key informant interviews, provides data to focus on four questions: (a) Do these programs simply accelerate move-outs for those who would have left without intervention? (b) Are program elements replicable given the importance of the local context in public housing move-outs? (c) How do housing authorities resolve tensions that arise between housing management and social service delivery? (d) What should housing authority response be to those who fail?

Case Management↗
PubMed2000

Options analysis of managed care contracting and regulation: theory and evidence.

Managed care contracts can be represented as bundles of options. In particular, the managed care provider is short a call option. To hedge the risk involved in such contracts, managed care contractors can construct several types of virtual put options, among them the ownership of facilities. Agency theory and options theory suggest that for-profit managed care plans, in the presence of debt, will engage in less hedging activity than will other managed care plans. Here, the authors test that hypothesis, using data for Florida HMOs in 1995, and they reject the null hypothesis. That managed care organizations act as if they are short a call option raises interesting regulatory issues, including the possibility of using a hedge-based regulatory scheme in place of a net-worth-based scheme.

Contract Services↗
PubMed2001

On the efficiency of public, welfare and private hospitals in Germany over time: a sectoral data envelopment analysis study.

This paper examines the efficiency of the German hospital sector over time and the relative efficiency of public, welfare (both nonprofit) and private (for-profit) hospital sectors using data from the Federal Statistics Office of German hospitals. Efficiency scores were computed using data envelopment analysis. The absolute efficiency of the hospital sector as a whole was found to have improved between 1991 and 1996. In this comparison, the empirical results showed that the hospitals in the public and welfare sector are relatively more efficient than private hospitals. Our results suggest that public, welfare and private hospital sectors have different best-practice frontiers; and that public and welfare hospital sectors appear to use relatively fewer resources than private hospitals. These results suggest differences in quality of care arising from ownership.

Efficiency, Organizational↗
PubMed1990

Hospital CEO turnover: modelling more or less durable places to work.

This study documents the rising rate of hospital CEO turnovers between 1978 and 1988, a trend that has accelerated since the introduction of Medicare's prospective payment system. Using data from the American Hospital Association, we identify characteristics of hospitals experiencing rapid CEO turnover. Results show that full utilization along with a positive operating margin can prolong the CEO's tenure but ownership and system membership specify the findings. For example, CEO turnover is higher in investor-owned, multihospital systems hospitals if they are small, if their costs are high and if they have recently joined a multi-hospital system. By contrast, in not-for-profit multihospital systems, turnover is higher if they have low occupancy and low operating margins. CEO turnover in not-for-profit, freestanding hospitals is higher in metropolitan areas and in the Western region of the US as well as in hospitals with low occupancy, low operating margins and lower costs per patient day. Governmental hospitals experiencing higher CEO turnover are small, metropolitan and tend to be located in any region except the Midwest. Many have recently joined a multi-hospital system and have experienced low operating margins.

Chief Executive Officers, Hospital↗
PubMed1996

A cost-constrained model of strategic service quality emphasis in nursing homes.

This study employed structural equation modeling to test the relationship between three aspects of the environmental context of nursing homes; Medicaid dependence, ownership status, and market demand, and two basic strategic orientations: low cost and differentiation based on service quality emphasis. Hypotheses were proposed and tested against data collected from a sample of nursing homes operating in a single state. Because of the overwhelming importance of cost control in the nursing home industry, a cost constrained strategy perspective was supported. Specifically, while the three contextual variables had no direct effect on service quality emphasis, the entire model was supported when cost control orientation was introduced as a mediating variable.

Cost Control↗
PubMed2005

Network of communities in the fight against AIDS: local actions to address health inequities and promote health in Rio de Janeiro, Brazil.

When combined with major social inequities, the AIDS epidemic in Brazil becomes much more complex and requires effective and participatory community-based interventions. This article describes the experience of a civil society organisation, the Centre for Health Promotion (CEDAPS), in the slum communities (favelas) of Rio de Janeiro, Brazil. Using a community-based participatory approach, 55 community organisations were mobilised to develop local actions to address the increasing social vulnerability to HIV/AIDS of people living in squatter communities. This was done through on-going prevention initiatives based on the local culture and developed by a Network of Communities. The community movement has created a sense of "ownership" of social actions. The fight against AIDS has been a mobilising factor in engaging and organising communities and has contributed to raising awareness of health rights. Local actions included targeting the determinants of local vulnerability, as suggested by health promotion workers.

Acquired Immunodeficiency Syndrome↗