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At least 19 recordsLinked to original sources
PubMed2002

Methadone at tapered doses for the management of opioid withdrawal.

BACKGROUND: Despite use in many countries of tapered methadone for detoxification from opiate, the evidence of efficacy to prevent relapse and promote lifestyle change has not been systematically evaluated. OBJECTIVES: To determine whether tapered methadone is effective to manage withdrawal from opioids. SEARCH STRATEGY: We searched: Cochrane Controlled Trial Register (Issue 1, 2000), MEDLINE (OVID 1966-2000), EMBASE (1980-2000); reference list of relevant articles; personal communication; conference abstracts; trials from pharmaceutical industry; Internet. SELECTION CRITERIA: All randomised controlled trials on the use of tapered methadone versus all other detoxification treatments, placebo and different modalities of methadone detoxification programs for the treatment of opiate withdrawal. DATA COLLECTION AND ANALYSIS: One reviewer assessed studies for inclusion and undertook data extraction. The overall process were confirmed by consultation between reviewers. MAIN RESULTS: 20 studies were included, with 1357 people randomised. 10 studies compared methadone with adrenergic agonists, 7 compared different modalities of methadone detoxification, 2 compared methadone with other opioid agonists, 1 study compared methadone with chlordiazepoxide one with placebo. 10 studies that compared methadone with adrenergic agonists showed clinical differences of the treatments; 6 studies that compared different methadone schedules, showed different withdrawal responses; 2 studies that compared methadone and other opioid agonists showed that methadyl acetate performed similarly to methadone, while propoxyphene produced more severe withdrawal symptoms and more drop-outs than methadone; chlordiazepoxide and methadone (1 study) resulted similar in terms of overall effectiveness; more severe withdrawal and more drop outs in the placebo group than in methadone one (1 study). The results indicate that tapered methadone and other medications used are effective although symptoms experienced differed according to the medication used and the program adopted. The medications are similar in terms of overall effectiveness. Improvements were achieved when other services supporting services were offered contemporaneously with detoxification. REVIEWER'S CONCLUSIONS: Data from literature are hardly comparable; programs vary widely with regard to duration, design and treatment objectives, along with reporting impairing the application of meta-analysis. The studies included confirm that slow tapering with temporary substitution of long acting opioid can reduce withdrawal severity. Nevertheless the majority of patients relapsed to heroin use, abstinence cannot be considered a goal as heroin dependence is a chronic, relapsing disorder and the purpose of detoxification should be to remove or reduce dependence on heroin in a controlled and human fashion and not a treatment for heroin dependence.

Humans↗
PubMedDate not supplied

Managing managed care. The task calls for an integrated management team.

Healthcare providers must learn the art of "managing care," a concept integral to but broader than managed care. Managing care has four dimensions: recruiting skilled operations managers; developing systems, procedures, practices, and protocols that meet the demands of capitation and risk management; fully integrating physician leaders; and preserving society's resources by providing care on the wellness, rather than the sickness, model. Managing managed care, which is now usually the task of a single executive, will tomorrow require a team comprising these four roles: The CEO articulates the system's vision, helps develop its strategic plan, and leads the effort to educate all its associates and employees about managed care. The operations leader (which may in fact be a group of operations executives) redesigns the systems organizations, redeploys its managers, and dismantles its obsolete methods. The physician leader (which may also be a group, rather than an individual) helps retool the system's practices and protocols in a way that enables it to deliver the highest quality of care at the lowest possible cost. The managed care executive acts as the broker between the system and insurance firms. In larger systems, this executive designs long-term partnerships between the system and insurers.

Catholicism↗
PubMed2000

Initial management strategies for dyspepsia.

BACKGROUND: This review considers management strategies (combinations of initial investigation and empirical treatments) for dyspeptic patients. OBJECTIVES: To determine the effectiveness, acceptability, and cost effectiveness of the following initial management strategies for patients presenting with dyspepsia (a) initial pharmacological therapy (including endoscopy for treatment failures) (b) early endoscopy (c) testing for Helicobacter pylori and endoscope only those positive (d) H.pylori eradication therapy with or without prior testing. SEARCH STRATEGY: Trials were located through electronic searches and extensive contact with trialists. SELECTION CRITERIA: All randomised controlled trials of dyspeptic patients presenting in primary care. DATA COLLECTION AND ANALYSIS: Data was collected on dyspeptic symptoms, quality of life and use of resources. MAIN RESULTS: Ten papers reporting 12 comparisons were found. Trials comparing proton pump inhibitors (PPI) with antacids (2 trials) and H2 receptor antagonists (3 trials), and of early endoscopy compared with initial acid suppression (3 trials) were pooled. PPIs were significantly more effective than both H2RA s and antacids. Relative risks (RR) and 95% CI were, for PPI: antacid 0.72 (0.64-0.80), PPI: H2RA 0.63 (0.47-0.85). Results for other drug comparisons were either absent or inconclusive. Early endoscopy was not more effective than initial prescribing (RR 0.90 (0.77-1.04), but current studies lack power. No eligible trials of H.pylori test and endoscopy or test and eradicate were found. REVIEWER'S CONCLUSIONS: PPIs are effective in the treatment of dyspepsia in these trials which may not adequately exclude patients with gastro-oesophageal reflux disease. The relative efficacy of H2RA and PPI is uncertain. Early investigation may benefit some patients with dyspepsia. The review will be updated shortly with several large trials that have recently been completed.

Anti-Bacterial Agents↗
PubMed1994

Case management: managing the nurse case manager.

Nurse executives and nurse managers have become proactive in response to the health care crisis by creating and implementing innovative health care delivery models such as nursing case management. Nursing case management utilizes a nurse as case manager and the unit-based system of managed care to achieve financial and clinical outcomes for target patient groups. Nurse managers can support the nursing case management model best by practicing good managerial skills, developing a participative style of leadership, and empowering the nurse case manager.

Employee Performance Appraisal↗
PubMed1997

Managing case management across the continuum: an organized response to managed care.

Case management is a core strategy for providing high-quality, cost-effective care in a managed care environment. Acute care case management programs most often originate as nursing-driven, hospital-based initiatives. Given the overwhelming trend toward vertical integration of health care organizations, hospital-based case management programs may be only an interim step toward a longer term strategy. Hospital and case management program leadership should consider how existing case management models can expand to meet patient and provider needs in an integrated health system or network environment. Key issues and strategies for designing a case management system based on continuum of care are described.

Case Management↗
PubMed2006

Local air quality management as a risk management process: assessing, managing and remediating the risk of exceeding an air quality objective in Great Britain.

Air quality is managed in Great Britain via an effects-based, risk management process designed to provide a dynamic solution to public health issues associated with elevated concentrations of seven specified air pollutants. This paper is concerned with an examination and evaluation of the process of Local Air Quality Management (LAQM) in Great Britain from the late 1980s to date as a risk management process. The statutory basis of LAQM process is provided by the Environment Act 1995. The Act provides a framework in which national and local actions are required to identify and remediate areas of poor air quality. Within this framework, the implementation of the process at national and local levels is considered, leading to an identification and assessment of risks in the formulation and implementation of air quality management policy and practice. Local Authorities began the process of Review and Assessment in 1999 and the first round of the process concluded in 2001. Following this, some 129 Local Authorities declared one or more Air Quality Management Areas (AQMAs). The Review and Assessment elements of the framework were subjected to an evaluation in 2001 and the essential elements of it were confirmed as fit for purpose. The evaluation led to a confirmation of the process of LAQM but also a simplification based on the experience of Round 1. Now, a two step process is required comprising of an Updating and Screening Assessment and, where a risk of exceeding an Air Quality Objective (AQO) is identified, a Detailed Assessment follows. The Government has identified a time scale for Review and Assessment through to 2010 and also introduced the requirement of a regular Progress Report in order that a Local Authority is able to address routine matters of air quality management. The risks inherent in epidemiological or scientific uncertainty are factored into the LAQM process at an early stage of the process and, by identifying the risks and subjecting them to regular review, the process provides a 'level playing field' across spatial and temporal scales. Whilst the process of LAQM described in this paper has been developed for Great Britain, the generic elements of the process are applicable to other countries challenged by air pollution problems which require both national and local action to resolve them.

Air Pollution↗
PubMedDate not supplied

Managed care in New Zealand: managed competition or managed collaboration?

Managed care is making major progress in New Zealand through independent practice associations (IPAs) now representing more than 50% of general practitioners. It is also being implemented by community groups, especially Maori, who see great potential in improving the health status of their people through this strategy. However, a significant conflict appears to be developing between achieving managed care through managed competition on the one hand and managed collaboration on the other. There appear to be fundamental flaws in the concept of managed competition. Evidence is emerging that managed collaboration is far more likely to be effective in achieving the Government's goals of improving health status and access and more cost-effective healthcare.

Budgets↗
PubMedDate not supplied

Global case management: Hong Kong. Care for the hospital-discharged frail elders by nurse case managers: a process evaluation of a longitudinal case management service project.

Using quantitative and qualitative methodology, a study was conducted on the process of case management performed by nurse case managers on a group of 45 post-discharged frail elderly patients in 2001-2002. The quantitative data provided the common reasons for client-initiated telephone calls to nurse case managers and the nurse case managers' interventions to these calls. Qualitative data yielded 9 major themes on which a sequential and dynamic process model of case management was conceptualized. Another 7 thematic descriptions on essential factors for the successful implementation of case management were configured in a dual-dimensional framework of staff and structural factors.

Aftercare↗
PubMed2004

Does managed care make a difference? Physicians' length of stay decisions under managed and non-managed care.

BACKGROUND: In this study we examined the influence of type of insurance and the influence of managed care in particular, on the length of stay decisions physicians make and on variation in medical practice. METHODS: We studied lengths of stay for comparable patients who are insured under managed or non-managed care plans. Seven Diagnosis Related Groups were chosen, two medical (COPD and CHF), one surgical (hip replacement) and four obstetrical (hysterectomy with and without complications and Cesarean section with and without complications). The 1999, 2000 and 2001--data from hospitals in New York State were used and analyzed with multilevel analysis. RESULTS: Average length of stay does not differ between managed and non-managed care patients. Less variation was found for managed care patients. In both groups, the variation was smaller for DRGs that are easy to standardize than for other DRGs. CONCLUSION: Type of insurance does not affect length of stay. An explanation might be that hospitals have a general policy concerning length of stay, independent of the type of insurance of the patient.

Arthroplasty, Replacement, Hip↗
PubMed2003

[Clinical management. Clinical management units. Management agreements].

Clinical management (CM) as a concept includes different innovating experiences in health care services management among developed countries, which were initiated during the late eighties and the first nineties. They were mostly due to the concern that political leaders had about their financial viability. CM, as far as it is understood in Spain, is an organizing model which considers the patient as the centre of the health system. It is guided towards disease, looking for continuous assistance and facilitates an autonomous management together with decentralization at the time of taking decisions. It involves professionals whose clinical practice, based on guides, medical records and care planning, incorporate the knowledge and methodology of "evidence based medicine". Clinical management units (CMU) are organizational types of CM, which implantation is spreading rapidly in the different national health care systems. They include a person who assumes responsibility for them, who act as the hospital directorship interlocutor and are autonomous at the time of managing the allocated resources related to their medical programmes and services. They have an information system adapted to their own needs and an outcome evaluation system which allows them "process" re-engineering. CMU's strengths and weaknesses are highly dependent on the professionals that integrate them. The CMU responsible carries out a management contract with the hospital directorship in which CMU competences, directorship's obligations, essential aspects to meet agreed goals, an outcome evaluation system and an incentives scheme are included.

Contract Services↗
PubMed2004

Managing under managed community care: the experiences of clients, providers and managers in Ontario's competitive home care sector.

In 1996, a newly elected government in the Province of Ontario, Canada, introduced a managed competition environment into the home care sector through the establishment of a competitive contracting process for home care services. Through 65 in-depth, semi-structured interviews conducted between November 1999 and January 2001, we trace the implementation of this competitive contracting policy within Ontario's newly established managed community care environment and assess the effects of competitive contracting against two sets of goals: (1). quality of care goals that consider continuity of care of paramount importance in the provision of home care; and (2). the managed competition goal of increased efficiency. In assessing the implementation of this policy against these goals, we highlight the conflicts that can arise in pursuing different policy goals in response to different formulations of the policy problem that underpin them. We map stakeholder experiences with the competitive contracting policy onto relevant contracting and managed competition literatures. When measured against the goals of quality of care and efficiency, the findings presented here offer a mixed review of the experiences to date with the competitive contracting process introduced in Ontario's home care sector and suggest improvements for managing future competitive contracting processes.

Attitude of Health Personnel↗
PubMedDate not supplied

A management technique for effective management of medical store in hospitals. Medical store management technique.

BACKGROUND: Almost one third of hospital' annual budget is spent on buying material and supplies including medicines. There is wide variation in cost of these items and effective management of store is necessary to ensure optimal use of money spent. OBJECTIVES: (i) To explore the feasibility of alphabetical analysis (where items are classified into A, B and C categories depending on their annual consumption value) in effective management of a medical store and to compare the present (fixed period re-order) and the proposed (fixed quantity re-order) as alternative inventory management technique. METHODS: Using multistage random sample technique, two sub-categories out of total of 37 listed in stock register (medicine) of a large hospital of Delhi were selected for detailed analysis. Alphabetical (ABC) analysis based on total annual consumption value of different items was done. Six medicines, the first and the last from each of the ABC categories, were also analysed for fixed quantity re-order. RESULTS: It was observed that ABC analysis, if practised, would allow effective control over two third of the total expenditure by controlling only one fourth of the items. The existing order size (based on fixed period re-order) was more than three times order size if based on fixed quantity re-order. CONCLUSIONS: Alphabetical analysis is a feasible and efficient technique for effective management of store in hospitals. Considerable financial savings is possible if the order size is based on fixed quantity re-order. RECOMMENDATIONS: The Assistant Store Officer should apply alphabetical analysis for more efficient management of the medical store. The present practice of fixed period re-order should be replace by fixed quantity re-order.

Cost Control↗
PubMed2002

[Usefulness of clinical pathway for community-acquired pneumonia as both an educational and a cost-management tool--an intervention study to compare the usefulness of management with a critical pathway to historical control of conventional management].

To delineate the usefulness of a clinical pathway for community-acquired pneumonia (CAP) as an educational tool as well as a cost management tool, we conducted a prospective controlled trial including a historical control group. Consecutive CAP patients classified under Category 3 of the American Thoracic Society and admitted to our hospital were evaluated. Using the clinical pathway method, 42 patients were managed between April and December 2000 as the intervention group, and 33 patients received conventional management between April and December 1999 as a historical control. For the intervention group, the clinical pathway, which was a time-task matrix formatted with consideration for guidance for disease treatment, laboratory tests, physical examinations, oxygen saturation monitoring, ambulation, diet, education for the patient and clinical outcomes, was implemented. We determined (1) educational effect, measured using reduction of delay caused by physicians; (2) quality of clinical practice, measured using the success rate of the initial antimicrobial therapy and readmission rate; and (3) economic efficacy, measured using health care cost and length of hospital stay. The delay caused by physicians was reduced by 16% in the Intervention Group (5% vs. 21%; p = 0.045). The success rates of initial antimicrobial therapy in the two groups were similar (85.7% vs. 84.8%). In the intention-to-treat set, the median value of health care cost was reduced by yen 48,055 (yen 277,460 vs. yen 325,515; p = 0.017) and the median length of a hospital stay was shortened by 3 days (8 vs. 11 days; p = 0.0007) in the Intervention Group. In conclusion, the clinical pathway had an educational effect on physicians regarding the management of hospitalized patients with community-acquired pneumonia as well as on the cost management.

Aged↗
PubMedDate not supplied

[Medical record management and risk management processes. State of the art and new normative guidelines about the organization and the management of the sanitary documentation in the National Health System or Hospital Trusts].

Recent health care reforms, the start of accreditation processes of health institutions, and the introduction also in the health system of risk management concepts and instruments, borrowed from the enterprise culture and the emphasis put on the protection of privacy, render evident the need and the urgency to define and to implement improvement processes of the organization and management of the medical documentation in the hospital with the aim of facilitation in fulfilment of regional and local health authorities policies about protection of the safety and improvement of quality of care. Currently the normative context that disciplines the management of medical records inside the hospital appears somewhat fragmentary, incomplete and however not able to clearly orientate health operators with the aim of a correct application of the enforced norms in the respect of the interests of the user and of local health authority. In this job we individuate the critical steps in the various phases of management process of the clinical folder and propose a new model of regulations, with the purpose to improve and to simplify the management processes and the modalities of compilation, conservation and release to entitled people of all clinical documentation.

Confidentiality↗
PubMed2005

Results of the European Survey on Anaemia Management 2003 (ESAM 2003): current status of anaemia management in dialysis patients, factors affecting epoetin dosage and changes in anaemia management over the last 5 years.

The European Survey of Anaemia Management 2003 (ESAM 2003) was a 1 day randomized survey conducted to assess anaemia management in dialysis patients 4 years after the introduction of the European Best Practice Guidelines. The survey included 8100 patients from 11 European countries and Israel. Overall, haemoglobin (Hb) levels > or =11.0 g/dl, as recommended by the guidelines, were achieved in 66% of patients. Only 48% of patients had adequate iron status, with transferrin saturation values missing for 27% and functional or absolute iron deficiency reported for 17 and 9%, respectively. In order to identify factors affecting epoetin dose and Hb levels, the countries were divided into two groups based on the percentage of patients with Hb levels > or =11.0 g/dl (>70% in group 1 and 60-70% in group 2). The most probable causes for better management in group 1 were administration of higher epoetin doses and better monitoring and management of iron status. In patients with Hb <11.0 g/dl, mean epoetin-alpha/beta doses were significantly lower for subcutaneous than intravenous (i.v.) administration, whereas mean doses were similar for both routes in patients with Hb > or =11.0 g/dl. When standardized for Hb levels, the dose ratio of i.v. epoetin-alpha/beta to i.v. darbepoetin alfa was 176:1 (95% confidence interval, 166:1-189:1). Limited comparisons between the eight countries that participated in ESAM 2003 and the original ESAM revealed that many patients still have haemoglobin levels below the current recommendations despite significant improvements in management of renal anaemia over the last 5 years.

Adolescent↗