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PubMed2000

Organization, management and operation of contemporary academic mass spectrometry service facilities.

The rapid evolution of mass spectrometry in the past 15 years has moved mass spectrometry facilities from the traditional model in which instruments were located in and used for a single department's samples to a distributed model servicing entire universities. In this paper we describe two such shared instrument facilities that have evolved from a base in a single department to facilities that service a broad clientele. The Purdue University Campus-wide Mass Spectrometry Center (CWMSC) is a decentralized facility with multiple sites on campus. The CWMSC is a limited-access facility in which samples are run by service facility personnel in close cooperation with investigators. The Vanderbilt University Mass Spectrometry Research Center (VU-MSRC) is a centralized facility in the medical school that provides services to the university at large. The VU-MSRC is an open-access facility in which users are expected to prepare and analyze their own samples under the guidance of a trained operator. Perhaps the most significant benefit achieved by these models has been the minimization of academic barriers and the resultant intellectual cross-fertilization that has greatly enriched research at institutions where this approach has been adopted. The advantages and limitations of both models are discussed in terms of the traditional academic paradigm of service, research and education.

Chemistry, Analytic↗

PubMed1992

Flexible sigmoidoscopy and the despecialization of gastrointestinal endoscopy. An environmental impact report.

BACKGROUND: Gastrointestinal endoscopy is a diagnostic and therapeutic tool for the prevention of premature death from cancer. Flexible equipment innovations during the 1970s increased the power of this technique dramatically. For family physicians and general internists, dissemination of these techniques started around 1979 and continued during the 1980s. METHODS: In this report, data describing the gradual reformation of primary-care cancer screening are discussed. RESULTS: For example, one longitudinal study revealed a sustained improvement in physician compliance with American Cancer Society guidelines associated with the advent of flexible sigmoidoscopy and short colonoscopy skills. For symptomatic patients, compliance increased from 2% to 79% over 5 years. CONCLUSIONS: Flexible sigmoidoscopy is now well accepted. Endoscopic biopsy, full colonoscopy, and polypectomy skills are now available to many primary-care physicians. This represents a technical advance, and it is a small part of a larger medical-care revolution in which technology is decentralized. This holds great promise for the eradication of premature death from colorectal cancer.

Colonoscopy↗

PubMed2006

Setting and organization of care for persons living with HIV/AIDS.

BACKGROUND: Treating the world's 40.3 million persons currently infected with HIV/AIDS is an international responsibility that involves unprecedented organizational challenges. Key issues include whether care should be concentrated or decentralized, what type and mix of health workers are needed, and which interventions and mix of programs are best. High volume centres, case management and multi-disciplinary care have been shown to be effective for some chronic illnesses. Application of these findings to HIV/AIDS is less well understood. OBJECTIVES: Our objective was to evaluate the association between the setting and organization of care and outcomes for people living with HIV/AIDS. SEARCH STRATEGY: Computerized searches from January 1, 1980 to December 31, 2002 of MEDLINE, EMBASE, Dissertation Abstracts International (DAI), CINAHL, HealthStar, PsychInfo, PsychLit, Social Sciences Abstracts, and Sociological Abstracts as well as searches of meeting abstracts and relevant journals and bibliographies in articles that met inclusion criteria. Searches included articles published in English and other languages. SELECTION CRITERIA: Articles were considered for inclusion if they were observational or experimental studies with contemporaneous comparison groups of adults and/or children currently infected with HIV/AIDS that examined the impact of the setting and/or organization of care on outcomes of mortality, opportunistic infections, use of HAART and prophylaxis, quality of life, health care utilization, and costs for patient with HIV/AIDS. DATA COLLECTION AND ANALYSIS: Two authors independently screened abstracts to determine relevance. Full paper copies were reviewed against the inclusion criteria. The findings were extracted by both authors and compared. The 28 studies that met inclusion criteria were too disparate with respect to populations, interventions and outcomes to warrant meta-analysis. MAIN RESULTS: Twenty-eight studies were included involving 39,776 study subjects. The studies indicated that case management strategies and higher hospital and ward volume of HIV-positive patients were associated with decreased mortality. Case management was also associated with increased receipt of ARVs. The results for multidisciplinary teams or multi-faceted treatment varied. None of the studies examined quality of life or immunological or virological outcomes. Healthcare utilization outcomes were mixed. AUTHORS' CONCLUSIONS: Certain settings of care (i.e. high volume of HIV positive patients) and models of care (i.e. case management) may improve patient mortality and other outcomes. More detailed descriptions of care models, consistent definition of terms, and studies on innovative models suitable for developing countries are needed. There is not yet enough evidence to guide policy and clinical care in this area.

Acquired Immunodeficiency Syndrome↗

PubMed2002

On-chip enzymatic assays.

This article reviews different possibilities for conducting enzymatic assays on microchip platforms, along with potential advantages, limitations, and selected examples of such biochips. Enzyme-based chips combine the analytical power and reagent economy of microfluidic devices with the selectivity and amplification features of biocatalytic reactions. "Lab-on-chip" devices thus allow enzymatic assays to be performed more rapidly, easily, and economically. Such assays usually rely on on-chip mixing and reactions (of the substrates and enzymes) in connection to separations (of the substrates or products). The realization of on-chip enzymatic assays thus requires understanding of how enzymatic reactions behave on a small scale and can be interfaced with separation microchips, and how the microfluidics can be tailored to suit the requirements of particular enzymatic assays. The goal is to obtain sufficient reaction times, without compromising the quality of the analytical separation. The versatility of such on-chip enzymatic assays offers great promise for decentralized testing of clinically or environmentally important substrates.

Electrophoresis, Capillary↗

PubMed2002

Microchip-based amperometric immunoassays using redox tracers.

A new chip-based electrochemical immunoassay protocol, based on the use of a ferrocene redox label, is described. Two reaction formats, based on direct (noncompetitive) and competitive modes of operation, were employed for illustrating the use of redox tracers in chip-based electrochemical immunoassays. The direct assay consisted of mixing the ferrocene-tagged antibody and the antigen analyte, a rapid electrophoretic separation of labeled free antibody and the labeled antigen/antibody complex, and a downstream anodic detection of the ferrocene tracer at gold-plated carbon screen-printed electrode detector. The competitive assay integrates precolumn reactions of the labeled antigen and the target antigen with the antibody with electrophoretic separation of the free and bound labeled antigens, along with amperometric detection of the redox tag. An internal standard has been used to normalize the peak area for the construction of calibration plots. Fundamental operating variables are examined and optimized. The use of a redox tracer offers the advantages of simplified protocol, wider linear range, higher stability, and higher separation efficiency compared to an analogous use of enzyme tags. The direct mouse-immunoglobulin G (IgG) assay and the competitive 3,3',5-triiodo-L-thyronine (T(3)) one were accomplished within less than 150 and 130 s (with field strengths of 256 and 192 V/cm), and offer minimum detectable concentrations of 2.5 x 10(-12) and 1 x1 0(-6) g/mL, respectively. Such use of redox labels for chip-based amperometric immunoassay protocols offers considerable promise for decentralized clinical or environmental testing.

Antigen-Antibody Complex↗

PubMed2005

Origin of corpses received by the anatomical institute at the University of Jena during the Nazi regime.

During the Nazi regime (1933-1945), the anatomical institute at the University of Jena received 2,224 corpses, of which approximately 200 originated from executions. The available data clearly suggest that a large portion of these 200 executed persons must be considered victims of Nazi crimes. Approximately an equal number of bodies were delivered from state nursing homes and mental institutions in the state of Thuringia during the same time period. The available data suggest that it is highly likely that many of them were victims of decentralized "euthanasia" programs. The remains of many prisoners of nearby labor camps, mostly from Eastern Europe, are listed in the body register at the institute as well. A group of anatomists and historians has investigated the institute's association with Nazi crimes. Apart from documenting the association, the aim of the investigation is to clarify the whereabouts of the corpses. In particular, it must be ascertained that none of the specimens publicly displayed in the anatomical collection of the Friedrich Schiller University originated in the context of Nazi crimes.

Academies and Institutes↗

PubMed1990

Federal policy and adolescent AIDS.

Adolescent AIDS policy in the United States is piecemeal at best. While funding for preventive education programs is extensive and growing, the effort remains largely uncoordinated and chaotic despite the best efforts of CDC. The public health system, like the educational system, is highly decentralized; state and county health officials have considerable authority over state and local public health programs. Adolescent AIDS health policy is essentially nonexistent. Aside from the usual sources of funding and services, such as Medicaid and the Maternal and Child Health block grant, there has been little recognition of the special problems confronting this population. Nor has the nation's AIDS research portfolio adequately reflected the threat of adolescent AIDS or the unique research questions needing investigation. As is so often the case, it seems particularly difficult to mobilize resources on behalf of adolescents, particularly those who are gay, live on the streets, or are intravenous drug users. Sadly, the nation seems incapable of recognizing the gravity of the threat posed by adolescent AIDS and HIV infection until the number of victims becomes overwhelming, as is the case now with adult AIDS.

Acquired Immunodeficiency Syndrome↗

PubMed2002

Provider case volume and outcome in the evaluation and treatment of patients with mammogram-detected breast carcinoma.

BACKGROUND: Practice volume may affect the outcome of patients with breast carcinoma. Defining factors that influence the relation of volume and outcome for the diagnosis and treatment of breast carcinoma is important, because breast carcinoma is common, and care is decentralized. METHODS: Community-wide diagnosis and treatment of mammogram-detected breast carcinoma was examined using claims data from a single insurer representing 25% of the regional population. Among 1001 mammogram-directed breast biopsies, the rate of breast carcinoma diagnosed by stereotactic core needle biopsy (SCNB) or excisional biopsy with needle localization (EBNL) and the rate at which breast-conserving surgery (BCS) was used were analyzed. Outcome and practice volume were examined for surgeons, radiologists, and medical centers. RESULTS: Two hundred twenty-four tumors were diagnosed by EBNL (604 diagnoses) and SCNB (397 tumors), for a 22.4% positive biopsy rate. The median number of procedures per physician was one. Positive biopsy rates for radiologists, surgeons, and medical centers did not correlate with practice volume. Positive biopsy rates for high-volume physician providers and medical centers ranged from 9% to 46%. The BCS rate was 45% and 64% for surgeons treating one or more than one claim, respectively. Tumor stage and surgeon case volume were the only independent predictors of BCS (P < 0.05). CONCLUSIONS: There is wide variation in diagnosis and treatment outcomes for patients with mammogram-detected breast carcinoma. Overall, practice volume was correlated with the use of BCS but not with the rate of positive biopsy. A wide variation in the positive biopsy rate among high-volume providers and medical centers suggests that volume of practice is not a surrogate for quality in the diagnosis of breast carcinoma.

Biopsy↗

PubMed2003

Quality of cold-pressed edible rapeseed oil in Germany.

Forty-eight cold-pressed edible rapeseed oils obtained from small- and medium-sized decentralized plants located all over Germany were characterized by different chemical parameters for their composition and by descriptive sensory evaluation. Between the different oils great differences could be noticed for each parameter. The results evidenced that additionally to the features given in the Guidelines for edible fats and oils of the German Food Codex, especially the sensory evaluation, the oxidation stability (Rancimat), content and the composition of tocopherols, the content of trans-fatty acids and the content of steradienes were crucial parameters to guarantee a high-quality product for the consumer.

Chlorophyll↗

PubMed1992

The Canadian health care system: a model for American to emulate?

The American health care system has the world's highest per capita costs and over 30 million citizens uninsured. The neighbouring Canadian system provides coverage for all basic medical and hospital services, at costs per capita that are about US$700 lower. Single-agency public funding allows tighter control of Canadian expenditures, and reduces administrative overheads. Hospitals are run as non-profit private corporations, funded primarily by a fixed annual allocation for operating costs. Most physicians are in private fee-for-service practice, but cannot charge more than the insured tariff negotiated between their provincial government and medical association. This approach, while attractive in its decentralization, tends to separate the funding and management of clinical services. Thus, hospital information systems lag a decade behind the USA, managed care initiatives are few, health maintenance organisations do not exist, and experimentation with alternative funding or delivery systems has been sporadic. Strengths of the system compared to the USA include: higher patient satisfaction, universal coverage, slightly better cost containment, higher hospital occupancy rates, and reduction in income-related rationing with more equitable distribution of services. Weaknesses in common with the United States are: cost escalation consistently outstripping the consumer price index with costs per capita second highest in the world, ever rising consumption of services per capita, inadequate manpower planning and physician maldistribution, poor regional co-ordination of services, inadequate quality assurance and provider frustration. Additional weaknesses include: an emerging funding crisis caused by the massive federal deficit, less innovation in management and delivery of care as compared to the USA, implicit rationing with long waiting lists for some services, and recurrent provider-government conflicts that have reduced goodwill among stakeholders. Thus, while the Canadian model has important advantages, it does not offer a panacea for American health care woes.

Canada↗

PubMedDate not supplied

Epidemiological measures in planning: observations from Sweden.

This article reviews how epidemiological measures can be used in health planning. Theoretical considerations are discussed together with empirical data from Sweden. Formulation of targets, priority settings, resource allocation and monitoring systems are some ways in which epidemiological data can improve health planning. One important lesson for planning is that problems related to health, inequalities in health, and access to care, must be made visible to politicians, health personnel and the public. Further, there is a need to complement a national health policy with a decentralized planning system that takes local conditions and needs into consideration.

Data Collection↗

PubMedDate not supplied

Rapid assessment of an African district health system. Test of a planning tool.

Occasional rapid health care system assessments are potentially useful for planning, for monitoring health care systems development over time, and for comparing health systems in different areas. With the decentralization of health sector management, for example in Kenya, there is a growing need of such assessments at district and sub-district levels. Can rapid assessments be conducted at affordable cost at these levels? What variables and methods are feasible? This paper reports on a rapid health system assessment conducted in rural Kenya during 1991. It required the completion at each health facility of a self-administered questionnaire which included questions on resources, health care programmes, management, service output, and prominent problems. It also included interviews with officers in charge of each health institution in the sub-district and an examination of records and reports available at each facility. The paper presents the range of issues addressed, the indicators used, the methods applied, the problems encountered, the costs of the assessment, and a small selection of the findings. We conclude that the assessment model is manageable at district level with modest planning and analysis support from central level. Field staff need more precise instructions for completion of the questionnaire, and more population-based estimates need to be calculated. Reassessment taking place every 3-5 years should be adequate for monitoring the process of change in the local health care system.

Community Health Centers↗

PubMedDate not supplied

The management of health services in Tanzania: a plea for health sector reform.

There are essentially four main approaches used in attempts to strengthen the management of health services in developing countries. These are: information system development; management training; use of planning and evaluation methodologies; and, health sector reform. As part of a collaborative research project based in Kisarawe District, Tanzania, we tested the hypothesis that a combination of the first three of these approaches would be sufficient to ensure that decisions and actions were taken to bring about major improvements in the management of health services. It was assumed that the decentralization, which took place as part of the 1982 reorganization of local government responsibilities, had provided managers with sufficient decision-making autonomy to allow them to bring about improvement in health service performance, provided that the other conditions were met. In fact, it was found that despite being presented with clear evidence of serious inefficiencies and inequities in the allocation of health resources, managers were often highly reluctant to decide upon actions which would alleviate the problems in situations where there were potential losers as well as winners, even if the benefits greatly outweighed the costs. This article argues that interventions based solely on training, information systems, or planning and evaluation protocols will make only marginal improvements to health service management, and that changes to the system as a whole are needed in order to provide managers and health professionals with incentives to rectify performance failings. Some ideas for health sector reform, to give managers power and incentives for improving efficiency and quality of care, are put forward. Since it is likely that the systemic problems of the health sector in Tanzania are shared by many other developing countries, the lessons drawn from this study probably have more general applicability.

Administrative Personnel↗

PubMedDate not supplied

Accreditation trends in Spain.

The profound political changes that followed the Spanish Constitution of 1978 have had a major influence in the healthcare offered to the Spanish population. The healthcare provision once centred in a single government agency, the Instituto Nacional de la Salud (INSALUD), is now being decentralized to the 17 autonomous regions established by the Constitution. Existing Spanish legislation, traditional accountability and established professional roles are determinant factors in defining the boundaries amongst the main stakeholders in the healthcare accreditation issue. Hospital accreditation has been traditionally understood by the central government agency as a way to assure regulated standards for licensing the operations of healthcare facilities. However, recent public concern over the quality of healthcare, health departments' accountability and health professional technical knowledge are now creating the search for a common approach to accreditation in Spain.

Accreditation↗

PubMedDate not supplied

The financing and organization of health services in poor rural China: a case study in Donglan County.

The socio-economic reforms launched in China in the late 1970s led to rapid economic growth and, with it, health sector resources expanded rapidly. The rural health services have benefited from the policies of economic reform, but not in an optimal way, particularly in poor areas. This article uses a case study of a poor county--Donglan--to illustrate that the fiscal decentralization combined with the financial responsibility system have resulted in a weakening of financing and provision of rural health services in poor areas. The need for health facilities to generate revenue has had unfortunate consequences for the style of medical care, such as over-prescription. In addition, the collapse of the cooperative medical system and the weakening of the three-tier network of rural health care in Donglan have jeopardized preventive programs and threaten access to basic health care for the peasants, especially the poor. The study found evidence that preventive programs have deteriorated over the past years, the poor had financial difficulty in access to services, particularly hospital care, health facilities at township and village levels have been run down, and less training and supervision have been provided by upper-level health facilities. The article concludes with recommendations for a strategy for rebuilding and strengthening the three-tier network of rural health care, and for establishing a cooperative medical and health care scheme to ensure that the majority of peasants in Donglan can be guaranteed access to basic health services. Limited health resources will therefore be better used.

China↗

PubMedDate not supplied

Health sector reform and STD/AIDS control in resource poor settings--the case of Tanzania.

Integration in health sector reform tends to mean horizontal interaction between vertical programmes. This can result in a larger more complex system than a set of individual vertical programmes. This article looks at the HIV/AIDS programme in Tanzania and the possible impact of system-wide health sector reform involving 'decentralization' and horizontal integration. It implies that the build-up to reform is likely to be costly, at least initially (although eventually the system may become more cost-effective). Integration can thus save resources, but it will also demand additional inputs, and may lead to reduced service output if operations depend on horizontal functions that fail to deliver. The objective of reform must be to create a reasonably sized, well-balanced, system which aims to maximize the output of quality services, both preventive and curative, and to facilitate community efforts to improve health. It is doubtful whether present reform efforts in Tanzania will contribute to more effective services, if not based on a more thorough analysis adapted to the local situation and given considerably more resources, both human and financial. There is also a risk that key preventive programmes, such as those aimed at the control of STD/AIDS, will be further weakened because of both integration with subsequent dependence on poorly functioning horizontal units and reduction in allocated resources.

Acquired Immunodeficiency Syndrome↗

PubMedDate not supplied

Organizational responses to a changing aid environment: the German Agency for Technical Cooperation (GTZ).

As a major European donor, German government development assistance faces a series of challenges. Recent political changes have raised expectations for demonstrable health outcomes as a result of German development assistance; there has been a deepened commitment to collaboration with other bilateral and multilateral donors; and partner countries are increasingly open to new approaches to development. German development assistance also reflects a new ethos of partnership and the shift to programmatic and sector based development approaches. At the same time, its particular organizational structure and administrative framework highlight the extent of structural and systems reforms required of donors by changing development relationships, and the tensions created in responding to these. This paper examines organizational changes within the German Agency for Technical Cooperation (Deutsche Gesellschaft für Technische, Zusammenarbeit) (GTZ), aimed at increasing its Regional, Sectoral, Managerial and Process competence as they affect health and related sectors. These include the decentralization of GTZ, the trend to integration of projects, the increasing focus on policy and health systems reform, increased inter-sectoral collaboration, changes in recruitment and training, new perspectives in planning and evaluation and the introduction of a quality management programme.

Community Participation↗

PubMedDate not supplied

Factors affecting the implementation of health legislation and its impact on the rural poor in China: a case study of implementation of the maternal and infant health care law in two poor counties.

This paper presents and discusses a case study of health legislation in China. In the transition to a market economy, legislation has been developed to offset the weakening in the central planning mechanism and political control that have historically influenced the behaviour of institutions and individuals in the Ministry of Health. There has been relatively little empirical examination of the implementation and impact of legislation as a tool for influencing health service provision in low-income countries. The study aimed to contribute towards filling this gap by exploring the factors affecting the implementation and impact of the Maternal and Infant Health Care Law, through a case study of two poor, rural counties in Chongqing municipality, China. The study found that key local actors perceive health legislation to be an important tool for safeguarding access to essential health care. However, the implementation of health legislation is inevitably a political process. The study illustrates the difficulties involved in efforts to influence provider behaviour through a national level legislative framework in a situation of decentralization of control over those providers, due to extreme regional variation in economic situations and limited resource inputs from the centre. Lessons are drawn for Chinese and international policy makers.

Child Health Services↗