WORKMEN'S COMPENSATION—Emphasis on Rehabilitation

Since the first law was enacted in 1911 major emphasis has been placed on monetary satisfaction of liability with insufficient attention to rehabilitation of the occupationally disabled.An effective workmen''s compensation program must have three basic goals: (1) Rehabilitation of the occupationally disabled; (2) assured, prompt, and adequate indemnity for the occupationally disabled or their survivors; and (3) minimal costs to employers and society commensurate with the first two goals. It is suggested that the medical societies of each state provide a broadly representative committee to advise the administrative agency on medical policies and practices. This committee would prepare registers of all physicians in each locality who are willing and qualified to accept calls for service to injured employees, would mediate complaints originating with the employee, the employer, the insurance carrier or the administrative agency, and would cooperate with the administrative agency in educational programs for all concerned.It is the physician''s responsibility to help the administrative agency in shifting the emphasis from indemnity to rehabilitation. The disabled employee is entitled to all services available to restore him to an earning capacity.     

Devolving authority for health care in Canada's provinces: 3. Motivations,attitudes and approaches of board members

OBJECTIVE: To obtain information from the members of the boards of devolved health care authorities on their motivations, attitudes and approaches, to evaluate their relative orientations to the expectations of provincial governments, local providers and community members, and to evaluate the influence of members'' being employees in health care or social services and being willing to stand for election. DESIGN: Mail survey conducted in cooperation with the devolved authorities during the summer of 1995. SETTING: Three provinces (Alberta, Saskatchewan and Prince Edward Island) with established boards and 2 provinces (British Columbia and Nova Scotia) with immature boards. PARTICIPANTS: All 791 members of the boards of devolved authorities in the 5 provinces, of whom 514 (65%) responded. OUTCOME MEASURES: Respondents'' declared motivations, levels of confidence in board performance and attitudes toward accountability; differences between members who were willing to run for election to boards and others and differences between members who were employees in health care or social services and others. RESULTS: The main motivations of board members were an interest in health care and a desire to be part of decision-making and their main concern was inadequacy of data for decision-making. Almost all (93%) felt that they made good decisions, and 69% thought that they made better decisions than those previously made by the provincial government. Most (72%) felt that they were accountable to all of the local citizens, although nearly 30% stated that they represented the interests of a specific geographic area or group. Attitudes toward their provincial governments were polarized, with half agreeing and half disagreeing that provincial rules restrict the board members. The board members who were employed in health care and social services and those who were willing to stand for election did not differ substantially from their counterparts, although potential electoral candidates were less likely than others to feel accountable to provincial-level constituencies (such as taxpayers and the minister of health) and more likely to represent the interests of a specific geographic area or group. Only a modest number of differences were found among members from different provinces. CONCLUSIONS: Board members'' strong feelings of accountability to and representation of local citizens could counteract the structural influences leading board members to favour the interests of provincial governments and providers.     

Is it possible to "achieve a balance" and meet the "safety net"? Paediatric Advisory Subcommittee to the North West Thames Regional Health Authority.

The government''s document Hospital Medical Staffing--Achieving a Balance--Plan for Action introduced the concept of a "safety net"--that is, a minimum safe level of staffing--of junior doctors in the acute specialties. The North West Thames Paediatric Advisory Group has therefore reviewed the implications and consequences of implementing the safety net in respect of children''s services. The group found that if a reasonable safety net was to be provided that enabled the services to stay within the projected junior staffing levels, maintain a balance, meet training needs, and reduce junior doctors'' hours of work, then changes in the organisation of the services would be required. Examining the options available showed that to achieve a safety net within the projected numbers of junior staff at least six paediatric units in the region would have to close. It is doubtful if there is the political will to support the very radical changes that would be needed in the distribution of services if the government''s recommendations in Achieving a Balance were to be implemented. The profession, the Department of Health, and the public must be made aware that the proposed changes in medical staffing will cause a fundamental change in the traditional pattern of delivery of health care.     

The Hospital's Perspective on Cost Containment

Cost containment has long been a concern of hospitals and the American Hospital Association (AHA). In recent years, however, cost containment has assumed a special prominence in hospitals, becoming both a political and social necessity. The hospitals'' and AHA''s activities in cost containment fall into four major categories: first, the Voluntary Effort to Contain Health Care Costs, of which AHA is a founding partner; second, administrative effectiveness; third, capital effectiveness, and, finally, medical effectiveness. Some programs to promote administrative effectiveness are shared administrative services, energy conservation, careful attention to staffing patterns and management effectiveness review. Capital effectiveness involves technology assessment and other means of deciding how to make the most of the hospital''s dollar. Medical effectiveness can be accomplished by such methods as medical audits, utilization reviews and shared clinical services.     

Curriculum change needed at Yale

The United States Congress has recently passed an important bill entitled, The Health Professionals Assistance Act of 1976. It seeks to right physician maldistribution in the country and curtail the over specialization of medical practitioners. Quotas have been set in terms of the number of medical school graduates who must enter primary care training programs over the next few years. Failure to comply risks loss of the federal capitation grant of twenty-one hundred dollars per student or about one million dollars a year in Yale''s case.The causes of physician maldistribution are discussed. Partial blame is ascribed to the medical schools themselves and recommendations are made for curriculum changes which if adopted may achieve better physician distribution without further government inroads into medical school affairs.     

Does the community want devolved authority? Results of deliberative polling in Ontario.

OBJECTIVE: To obtain and contrast the informed opinions of people in five decision-making groups that could have a role in devolved governance of health care and social services. DESIGN: Deliberative polling. SETTING: Three rural and three urban communities selected from the 32 areas covered by a district health council in Ontario. PARTICIPANTS: A total of 280 citizens from five potential decision-making groups: randomly selected citizens, attendees at town-hall meetings, appointees to district health councils, elected officials and experts in health care and social services. INTERVENTION: Participants'' opinions were polled during 29 structured 2-hour meetings. MAIN OUTCOME MEASURES: Participants'' opinions on their personal willingness and their group''s suitability to be involved in devolved decision making, desired type of decision-making involvement, information preferences, preferred areas of decision-making involvement and preferred composition of decision-making bodies. RESULTS: Mean attendance at each meeting was 9.6 citizens. Although there were some significant differences in opinion among the five potential decision-making groups, there were few differences among citizens from different geographic areas. A total of 189 (72%) of people polled were personally willing to take on a role involving responsibility for overall decision-making, but far fewer thought that their group was suited to taking on responsibility (30%) or a consulting role (55%). Elected officials were the most willing (85% personally willing, 50% thought their group was suitable) and randomly selected citizens the least willing (60% personally willing, 17% thought their group was suitable) to take responsibility for overall decision making. Most citizens polled indicated less interest in involvement in specific types of decisions, except for planning and setting priorities, than in overall decision making. Only 24 participants (9%) rated their own group as suitable to take responsibility for raising revenue, 91 (33%) deemed their group suited to distribution of funds and 108 (39%) felt their group was suitable for management of services. People in all five groups ranked health care needs (mean rank 1.5 out of four options) as the most important and preferences (mean rank 3.6) as the least important information. They rated a combination body involving several community groups as the most suitable overall decision-making body (8.8 on 10-point scale). Participants favoured the representation of elected officials, the provincial government and experts on combination bodies responsible for the specific types of decisions. Overall, as the complexity of devolved decision making became clear, participants tended to assign authority to traditional decision makers such as elected officials, experts and the provincial government, but also favoured a consulting role for attendees at town-hall meetings (i.e., interested citizens). CONCLUSION: There are significant differences among groups in the community in their willingness to be involved, desired roles and representation in devolved decision making on health care and social services in Ontario.     

COMMUNITY MENTAL HEALTH SERVICES—Operation in San Jose

Recent attempts to cope with the growing and costly problem of mental illness are progressively emphasizing prophylaxis and early detection and treatment. California has joined this trend forcefully since the passage of the Short-Doyle Act in 1957.San Jose is one of the communities with a Community Mental Health program, financed 50 per cent by the local government and 50 per cent by the State of California. It implements its program by offering consultative services to the city''s public health nurses, police officers, teachers, social workers, ministers, sanitarians and members of staffs of a number of public and private agencies.Results of the program have been: (1) Increased demand for education in mental health; (2) growing number of requests for case consultation in lieu of patient-referral to already overburdened psychiatric facilities, and (3) growing recognition by consultees of the importance of their own self-awareness.     

Making our offices universally accessible: guidelines for physicians

OBJECTIVE: To develop recommendations for office-based physicians who wish to make their offices accessible to all patients. OPTIONS: Include taking steps to make offices more accessible, or not; offices may be accessible to varying degrees. OUTCOMES: Outcomes of accessibility involve patient-care, economic, ethical and legal issues. Stakeholders in these outcomes include patients, physicians, government and society. EVIDENCE: Data were obtained from a series of searches of MEDLINE, CINAHL and Healthstar (previously Health) databases for articles on disability and family medicine, primary (health) care and family practice, and on access and offices, and health services accessibility, and from a telephone survey of 50 stakeholders. VALUES: A high value was placed on services to persons with disabilities and on stakeholder input. Universal accessibility was valued as an overall goal; improved accessibility was also highly valued. BENEFITS, HARMS AND COSTS: Benefits to patients include improved access to care as guaranteed by the Canada Health Act and in keeping with provincial Human Rights Codes. Benefits to physicians include contact with a broader patient population and freedom from fear of litigation. Costs of improved accessibility vary depending on individual circumstances and on whether an office is being built or renovated; some improvement costs are minimal. RECOMMENDATIONS: All physicians should take measures to improve practice accessibility. Improved access should be considered in each of the following areas: transportation and entrance to the facility, entrance to the office, waiting rooms, rest rooms, examination rooms, general building features and other features. VALIDATION: No similar guidelines exist. To assess the content validity of these guidelines, the authors had a draft document reviewed by 18 stakeholders. All specific recommendations met the minimum criterion of adherence to current legislation, including national and provincial building codes. The specific recommendations are endorsed by the Canadian Paraplegic Association (national and Ontario offices), the DisAbled Women''s Network (Ontario) and the Centre for Independent Living (Toronto). SPONSORS: Development of these guidelines was supported in part by the Department of Family and Community Medicine, Toronto Hospital, Toronto, Ont.     

Effects of Type of Health Insurance Coverage on Colorectal Cancer Survival in Puerto Rico: A Population-Based Study

Colorectal cancer represents a major health problem and an important economic burden in Puerto Rico. In the 1990''s, the Commonwealth of Puerto Rico implemented a health care reform through the privatization of the public health system. The goal was to ensure access to health services, eliminate disparities for medically indigent citizens and provide special coverage for high-risk conditions such as cancer. This study estimates the 5-year relative survival rate of colorectal cancer and the relative excess risk of death in Puerto Rico for 2004–2005, by type of health insurance coverage; Government Health Plan vs. Non-Government Health Plan. Colorectal cancer in advanced stages was more common in Government Health Plan patients compared with Non-Government Health Plan patients (44.29% vs. 40.24 had regional extent and 13.58% versus 10.42% had distant involvement, respectively). Government Health Plan patients in the 50–64 (RR = 6.59; CI: 2.85–15.24) and ≥65 (RR = 2.4; CI: 1.72–4.04) age-groups had the greater excess risk of death compared with Non-Government Health Plan patients. Further studies evaluating the interplay of access to health services and the barriers affecting the Government Health Plan population are warranted.     

Obstetric anaesthetic and analgesic services in Wales.

A survey of obstetric anaesthetic services in Wales covering 21 major units in which over 31 000 deliveries take place annually showed inadequacies in staffing at consultant and resident anaesthetist level. At least 20 additional consultant sessions were required to meet the recommendations of the Association of Anaesthetists of Great Britain and Ireland. If patients'' requests for epidural analgesia are to be met some reorganisation and centralisation of facilities is needed.     

The Development and Organization of a Children's Psychiatric Hospital

Thistletown Hospital is a children''s psychiatric hospital which was established by the Department of Health of the Province of Ontario. Special legislation permitting control of the admissions procedures was enacted. The administrative organization consists of a series of committees made up of the heads of hospital departments. An advisory board of distinguished psychiatrists and psychologists advises the Minister of Health directly on major policy changes or innovations envisaged for the hospital. Clinical organization is related to four functions: (1) service (treatment and assessment), (2) research, (3) training of staff, and (4) community education.The basic units of the hospital are related to the treatment or research design necessary in special diagnostic categories. A children''s psychiatric hospital should not be restricted to in-patient facilities but should consist of a totally community-oriented service.     

Community participation in health care decision making: is it feasible?

Health care reform strategies proposed by provincial governments include decentralized funding and increased public participation in decision making. These proposals do not give details as to the public participation process, and a number of questions have been raised by the experience of some communities. Which citizens should form the decision-making group? What information do they need? What kinds of decisions should they make? What level of participation should they have? The results of a survey by Abelson and associates (see pages 403 to 412 of this issue) challenge the assumption that "communities" are willing to participate in health-care and social-service decision making. Willingness varied according to the composition of the groups polled, and participants'' support for traditional decision makers increased after the complexities of the decision-making process were discussed. However, whereas their study measured willingness to participate at one point in time only, experience gained from Ontario''s Better Beginnings, Better Futures project indicates that, given sufficient time, "ordinary" citizens are willing and can acquire the skills needed to decide how resources should be allocated for social services.     

Informal complaints procedure in general practice: first year's experience.

OBJECTIVE--To evaluate the first year''s experience of an informal patient complaints system that encourages extensive patient participation. DESIGN--Audit of an informal complaints procedure. SETTING--The Marylebone Health Centre, London. SUBJECTS--39 complaints received over the audit period. MAIN OUTCOME MEASURES--Types of complaints (administrative, about doctors or medical care or both, staff about patients, mixed, other) and resolution of complaints (how complaints were dealt with and their resolution). RESULTS--37 of the 39 complaints were resolved within two weeks. Two complaints sent direct to the family health services authority were resolved (with patients'' agreement) by the informal complaints procedure. CONCLUSIONS--The informal complaints procedure was more cost effective than the family health services authority system and was comparatively straightforward to implement within the practice without major organisational restructuring. The two way process of the procedure ensured patients received a quick response to complaints and helped morale of health centre staff.     

Reforming the Department of Health's research and development policy: from the devil to the deep blue sea?

Research into health and social services in Britain is largely funded by the Department of Health. Regional NHS research and development has recently been reformed and a new report now proposes replacement of the 13 research units funded by the department with three or four large multidisciplinary centres. Evidence to support such a step is lacking, and many criticisms of the existing units arise from poor departmental planning rather than deficiencies of the units themselves. Large units may make research less responsive to the department''s needs, and it is essential that the proposed new structure is thoroughly evaluated before it is introduced.     

Report of the Canadian Hypertension Society's consensus conference on the management of mild hypertension.

Since the publication in 1977 of joint recommendations by the Canadian Cardiovascular Society, the Canadian Heart Foundation and the Ontario Council of Health on the detection and management of hypertension in Canada, several clinical trials on the efficacy of antihypertensive drug treatment in patients with mild hypertension have been undertaken. The Canadian Hypertension Society (CHS) felt that the results of these trials should be reviewed to determine whether existing recommendations on treatment should be changed. Three expert panels appointed by the CHS reviewed evidence on the clinical efficacy of antihypertensive therapy, the diagnosis of hypertension and the treatment of mild hypertension, and formulated recommendations on the care of mildly hypertensive patients in Canada. A consensus conference of biomedical scientists, practising physicians and government representatives reviewed and reached agreement on the panels'' recommendations. The final recommendations of the conference are presented in this report.     

Containing Ontario's hospital costs under universal insurance in the 1980s: what was the record?

In recent years the Ontario government has been concerned that the proportion of public expenditures devoted to health care is at an all-time high. In addition, the media have devoted considerable attention to specific incidents that may represent inadequate funding of hospital services. To shed light on the debate on health care expenditures we analysed the trend in expenditures of Ontario''s hospital sector in the 1980s in terms of the amount of inputs (e.g., labour) used to produce hospital services (e.g., a patient-day or admission) and after adjustment for general inflation. As in the 1970s the number of inputs grew relatively slowly during the 1980s. Inputs per patient-day grew at an annual rate of 0.46% and inputs per admission at an annual rate of 2.4%. Cost increases were largely accounted for by hospital wage increases; this could have been due to Ontario''s rapidly expanding economy. These findings indicate that Ontario has continued to be successful in containing the number of inputs used in the hospital sector. However, after two decades of substantial success with publicly acceptable cost control, the government faces increased scrutiny as the media and the public focus attention on several areas of perceived inadequate funding in health care services.     

The Scale of Faith Based Organization Participation in Health Service Delivery in Developing Countries: Systemic Review and Meta-Analysis

The extent of faith-based organizations'' participation within the overall health systems of developing countries is unclear. Recent reports state that faith-based organizations play a substantial role in providing healthcare in developing countries, cited in some publications as up to 70% of all healthcare services. The data behind these numbers are sometimes difficult to pinpoint and seem at odds to national and regional survey data. In an effort to quantify the contribution of faith-based organizations to healthcare delivery in low- and middle-income countries, we undertook a systematic review of the literature and conducted a new analysis of relevant Demographic and Health Survey data from 47 countries. Our findings demonstrate that the magnitude of healthcare provided by faith-based organizations may be lower than previously estimated. Understanding the scale of FBO-provided medical care is important for health sector planning, and more accurate and complete estimates are needed.     

Recommendations for ensuring early thrombolytic therapy for acute myocardial infarction. The Heart and Stroke Foundation of Canada,the Canadian Cardiovascular Society and the Canadian Association of Emergency Physicians for the Emergency Cardiac Care Coalition.

OBJECTIVE: To recommend practical steps to ensure early thrombolytic therapy and thereby reduce mortality and morbidity associated with acute myocardial infarction (AMI). OPTIONS: Various factors were considered that influence time to thrombolysis related to patients, independent practitioners and health care systems. OUTCOMES: Reduction in morbidity and mortality associated with AMI. EVIDENCE: Early initiation of thrombolytic therapy reduces morbidity and mortality associated with AMI. The ECC Coalition analysed the factors that might impede early implementation of thrombolytic therapy. VALUES: Published data were reviewed, and recommendations were based on consensus opinion of the Emergency Cardiac Care (ECC) Coalition. The ECC Coalition comprises 20 professional, nongovernment and government organizations and has a mandate to improve emergency cardiac care services through collaboration. BENEFITS, HARMS AND COSTS: Early thrombolytic therapy reduces morbidity and mortality associated with AMI. Implementation of the recommendations will result in reduced time to thrombolytic therapy, streamlining of current practices and enhanced cooperation among health care professionals to expedite care. Depending on existing practices, implementation may require protocol development, and public and professional education. Although costs are associated with educating the public and health care professionals, they are outweighed by the financial and social benefits of reduced morbidity and mortality. RECOMMENDATIONS: Early recognition of AMI symptoms by the public and health care professionals, early access to the emergency medical services system and early action by emergency care providers in administering thrombolytic therapy (within 30 minutes after the patient''s arrival at the emergency department). VALIDATION: No similar consensus statements or practice guidelines for thrombolytic therapy in Canada are available for comparison.     

县域生态保护成效评估方法——以峨山县为例

县域是我国基本的行政单元,建立县域生态保护成效评估方法是完善我国生态文明制度建设重要任务。生态系统生产总值(GEP)是指一定区域在一定时期内生态系统为人类福祉提供的最终产品与服务及其价值总和,开展县域GEP核算可以客观反映县域的生态系统状况和生态保护的成效。以省级生态文明县——峨山彝族自治县为例,研究了县域GEP的核算指标体系和核算方法,开展了峨山县GEP核算,分析了峨山县GEP构成及其变化趋势。结果表明:(1)峨山县生态系统产品与服务可以分为产品提供、调节服务和文化服务3大类15项;(2)2015年,峨山县GEP为158.42亿元,气候调节功能和水源涵养功能是最主要的服务功能,二者总和占当年GEP的62.02%;(3)2000年以来,峨山县GEP明显提高,剔除价格因素后,共增加了25.04%,其中产品提供和文化服务功能价值提升明显,分别增加了236.25%和3004.06%。调节服务价值稳中有升,增加了1.30%。本研究表明,现有的生态环境监测数据和经济社会统计数据基本上可以支撑县域GEP的核算,同时县域GEP的变化能够体现出生态系统的保护成效,并为完善政府绩效考核制度提供依据。     

Patients' Perceptions on the Performance of a Local Health System to Eliminate Leprosy,Paraná State,Brazil

Background

In Brazil, leprosy has been listed among the health priorities since 2006, in a plan known as the “Pact for life” (Pacto pela Vida). It is the sole country on the American continent that has not reached the global goal of disease elimination. Local health systems face many challenges to achieve this global goal. The study aimed to investigate how patients perceive the local health system''s performance to eliminate leprosy and whether these perceptions differ in terms of the patients'' income.

Methodology/Principal Findings

A cross-sectional study was conducted in Londrina, State of Paraná, Brazil. Interviews were performed with the leprosy patients. The local health system was assessed through a structured and adapted tool, considering the domains judged as good quality of health care. The authors used univariate, bivariate and multivariate analyses. One hundred and nineteen patients were recruited for the study, 50.4% (60) of them were male, 54.0% (64) were between 42 and 65 years old and 66.3% (79) had finished elementary school. The results showed that patients used the Primary Health Care service near their place of residence but did not receive the leprosy diagnosis there. Important advances of this health system were verified for the elimination of leprosy, verifying protocols for good care delivery to the leprosy patients, but these services did not develop collective health actions and did not engage the patients'' family members and community.

Conclusions/Significance

The patients'' difficulty was observed to have access to the diagnosis and treatment at health services near their homes. Leprosy care is provided at the specialized level, where the patients strongly bond with the teams. The care process is individual, with limited perspectives of integration among the health services for the purpose of case management and social mobilization of the community to the leprosy problem.