Rethinking the deserving body: altruism,markets, and political action in health care provision

Abstract

I seek to understand two dimensions in the evolution and practices of medical institutions in the USA. First, I ask, how and why do medical organizations limit, suspend, or redirect profit-oriented functions to abide by principles of altruism and still survive in a competitive market economy? Reaching out to poor and immigrant populations entails non-economic factors, including the deployment of religious and humanitarian narratives. Conversely, the extent and character of legislative actions supporting philanthropic endeavours is closely related to mobilization at the grassroots level. I investigate the ways in which community organizations bring about changes to support practices that confound, at least to some extent, market expectations and underscore the significance of political action to secure health care services on behalf of low-income populations, including immigrants.     

手术医疗收费结构比例分析及对策探讨

目的 通过分析手术医疗收费结构比例,找出医疗收费结构中的缺陷。方法 对639例手术医疗收费情况进行数据处理,分析不同类别手术费用间价格的差异性。结果 在手术及麻醉医疗消费中,药品、耗材的费用在医疗消费中所占比例较大,医务人员的劳动价值在费用中未合理体现。结论 医疗费用的合理管控需要采取科学有效的措施作为保障,医务人员劳动价值需要公平合理的体现在医疗费用中。     

Obesity and the Use of Health Care Services

Objective: This study investigated differences in the use of health care services and associated costs between obese and nonobese patients. Research Methods and Procedures: New adult patients (N = 509) were randomly assigned to primary care physicians at a university medical center. Their use of medical services and related charges was monitored for 1 year. Data collected included sociodemographics, self‐reported health status using the Medical Outcomes Study Short Form‐36, evaluation for depression using the Beck Depression Index, and measured height and weight to calculate BMI. Results: Obese patients included a significantly higher percentage of women and had higher mean age, lower mean education, lower mean health status, and higher mean Beck Depression Index scores. Obese patients had a significantly higher mean number of visits to both primary care (p = 0.0005) and specialty care clinics (p = 0.0006), and a higher mean number of diagnostic services (p < 0.0001). Obese patients also had significantly higher primary care (p = 0.0058), specialty clinic (p = 0.0062), emergency department (p = 0.0484), hospitalization (p = 0.0485), diagnostic services (p = 0.0021), and total charges (p = 0.0033). Controlling for health status, depression, age, education, income, and sex, obesity was significantly related to the use of primary care (p = 0.0364) and diagnostic services (p = 0.0075). There was no statistically significant relationship between obesity and medical expenditures in any of the five categories or for total charges. Discussion: Obesity is a chronic condition requiring long‐term management, with an emphasis on prevention. If this critical health issue is not appropriately addressed, the prevalence of obesity and obesity‐related diseases will continue to grow, resulting in escalating use of health care services.     

Physician-Patient Communication in the Orthopedic Clinic: Surgeon-Identified Challenges

BackgroundEffective communication between the physician and the patient is crucial to quality healthcare. The orthopedic surgery clinic setting provides an environment for cultivating the physician-patient relationship, eliciting diagnostic data, and developing treatment strategies. However, little is known about the orthopedic surgeon perspective on communicating with patients. The purpose of the study was to identify patient communication and care issues faced in the orthopedic surgery clinic setting that physicians categorize as challenging.MethodsAll surgeons in the department of orthopedics in a large tertiary care center were invited to respond to an online survey on common communication challenges. Physicians were asked to rate 13 challenges identified by the literature and opinion leaders using a four-point Likert scale ranging from “Not at all challenging” to “Extremely challenging”. In addition, the survey included open ended questions regarding common challenges in communicating with patients and types of encounters, and thematic analysis was applied. Mean scores were calculated.ResultsNineteen orthopedic surgeons completed the survey and were included in the analysis. Orthopedic surgeons identified misaligned expectations for surgical intervention for a nonsurgical diagnosis as the most challenging encounter in the clinic (16/19). Managing postoperative patient expectations (14/19) and communicating with patients who were dissatisfied with their surgical outcome (13/19) were also commonly rated as particularly challenging. Open ended responses echoed these ratings and additional difficulty facilitating patient understanding of complex information as common communication challenges.ConclusionCommon challenges in the orthopedic clinic often surround managing patient expectations and providing effective explanations, particularly where physicians perceive a surgical intervention as inappropriate for addressing the patient complaint. Identifying these issues can guide training efforts to help orthopedic physicians in managing these and improving communication. These findings can also provide basis for collecting information about communication challenges from orthopedic surgeons across institutions. Level of Evidence: IV     

Lifestyle factors and quality of life among primary health care physicians in Madinah,Saudi Arabia

BackgroundPhysicians are considered to be a high-risk population for a poor quality of life (QoL), but few studies of lifestyle factors include the QoL among them.ObjectivesThis study aimed to investigate the relationship between lifestyle factors and a positive QoL among primary health care (PHC) physicians.MethodsA cross-sectional study was conducted at 20 primary healthcare centers in Madinah, Saudi Arabia. A self-administered questionnaire was used, including sociodemographic characteristics, lifestyle data, and the short version of the World Health Organization Quality of Life questionnaire. Appropriate statistical analyses were used, including multivariate logistic regression models.ResultsThe response rate was 85.7% (72/84) physicians. The mean score of the total QoL and its four studied domains (physical, psychological, social, and environmental) was relatively high, with no statistically significant difference between the consultants and general practitioners. The positive total QoL in this study was significantly lower among physicians with obesity (OR = 0.55, 95%CI = 0.25–0.97), those using butter and animal fat for cooking (OR = 0.10, 95%CI = 0.02–0.81), and those eating meals out > 3 times per week (OR = 0.30, 95%CI = 0.10–0.90). Although non-significant, vegetable consumption and a high level of physical activity were associated with a positive QoL, with adjusted ORs of 2.5 (95%CI = 0.82–7.58) and 1.5 (95%CI = 0.33–6.65), respectively.ConclusionThe findings indicate a relatively good QoL among the participating physicians; however, a lower QoL was associated with unhealthy lifestyle factors. QoL was significantly associated with obesity, cooking practices, and eating meals from restaurants.     

Hypo- vs. normofractionated radiation therapy in breast cancer: A patterns of care analysis in German speaking countries

Aim and backgroundTo assess the use of hypofractionated (HG-RT) versus normofractionated radiation therapy (NF-RT) in Breast Cancer in German speaking countries.Materials and methodsBetween July 2017 and August 2017, an email-based survey was sent to all 1408 physicians that are members of the German Society of Radiation Oncology (DEGRO). The survey was completed by 180 physicians including 10 private practice owners and 52 heads of departments. The majority (82.1%) of the participants had >15 years of experience in radiation therapy (RT).ResultsThe majority (83.9%) of the heads of the departments agreed on using the normofractionated regimen of RT as standard treatment for breast cancer. Several physicians were skeptical about HF-RT with 6.5% of the heads refusing to use HF-RT. 40.3% of the departments had not seen the new German guidelines suggesting HF-RT as the standard treatment for all patients as positive or merely adopted a neutral position toward the guidelines (33.9%). The main points of criticism were increased side effects, an impaired toxicity profile and insufficient data. Most departments (46.8%) that perform HF-RT do so in an individual based manner.ConclusionsHF-RT remains controversial in German speaking countries. Our data shows that NF-RT remains the predominant method of treatment. HF-RT is only used in a defined group of patients as most German physicians agree that particular patients, especially those at higher risk of RT late effects, may benefit from a less intense, extended fractionation schedule.     

政府补偿与监管机制改革对公立医疗卫生机构科教与学科建设的影响分析

目的 分析政府补偿与监管机制改革对公立医疗卫生机构教学、科研以及学科建设的影响。方法 通过对上海市闵行区的机构调查,收集并分析2008—2012年3所公立综合性医院和12家社区卫生服务中心的医学教育、科研项目、论文发表及重点学科建设状况的相关数据。结果 闵行区公立综合性医院和社区卫生服务中心的医学教育和科研能力有所提升,重点学科建设也有所加强;但仍然存在教学能力薄弱,科研水平层次偏低,缺乏高质量的重点学科等问题。结论 政府补偿与监管机制改革在一定程度上强化了公立医疗机构的医学教育、科研能力和学科建设,但未来需进一步加大对科教和学科建设的鼓励和支持力度。     

医务社工与志愿者在医院服务管理中作用的评价

目的 通过实证调查采集患者、医务工作者和志愿者对医务社工及志愿者工作的评价,解析医务社工及志愿者在医院服务管理中的作用。方法 采用问卷调查、文献查阅、深度访谈法,调研上海市三家三级甲等公立医院获取第一手资料。结果 调查结果显示,患者、医务人员及医务管理人员高度认可医务社工与志愿者在医院服务管理的作用。结论 医务社工和志愿者在医院服务管理中能发挥独特的作用,可以增进医患沟通,缓解或预防医患矛盾,给患者更多人文关怀和增值服务,一定程度上解决医患之间的诊治经费问题,提升服务品质、降低人力成本,应当得到全社会更多的重视。     

对某三甲医院临床医疗告知行为现状的调查与分析

??????? 目的 基于对医生告知行为的调查,发现目前临床中存在的医疗告知行为方面的不足。方法 采用随机抽样的方式对217名医务人员进行医疗告知行为情况的调查。结果 医疗机构在医疗告知方面存在缺陷：医疗告知主体高年资医师参与度不高;医疗告知对象主要是患者的近亲属,而不是患者本人;医疗告知注重风险告知,而忽视了对患者病情及医疗方案等内容的告知。结论 目前临床工作中在医疗告知方面不足,医疗机构应该通过完善制度、培训医师及管理部门加强监管等方面来保障医疗知情告知起到其应有的作用。     

Structural violence and compassionate compatriots: immigrant health care in South Florida

Abstract

Based on more than twenty in-depth interviews with health care professionals in Miami-Dade County clinics and hospitals, this study explores immigrant access to health care. We focus on some of the debates that took place during the 2009–10 process of US health care reform, which uncovered a pervasive public fear that immigrants illegitimately access health care. This study found the opposite: immigrants in South Florida often avoid primary health care even when offered freely and legally. This is because of bewilderment about bureaucratic requirements, fear of deportation and bills, and cultural folkways. We present the former two barriers as forms of structural and symbolic violence. We conclude by describing South Florida's compassionate compatriots, as a means by which immigrants can be guided through the health care system.     

Practice facilitation for improving cardiovascular care: secondary evaluation of a stepped wedge cluster randomized controlled trial using population-based administrative data

BackgroundPractice facilitation (PF), a multifaceted approach in which facilitators (external health care professionals) help family physicians to improve their adoption of best practices, has been highly successful. Improved Delivery of Cardiovascular Care (IDOCC) was an innovative PF trial designed to improve evidence-based care for people who have, or are at risk of, cardiovascular disease (CVD). The intervention was found to be ineffective as assessed by a patient-level composite score based on chart reviews from a subsample of patients (N = 5292). Here, we used population-based administrative data to examine IDOCC’s effect on CVD-related hospitalizations.MethodsIDOCC used a pragmatic, stepped wedge cluster randomized controlled design involving primary care providers recruited across Eastern Ontario, Canada. IDOCC’s effect on CVD-related hospitalizations was assessed in the 2 years of active intervention and post-intervention years. Marginal and mixed-effects regression analyses were used to account for the study design and to control for patient, physician, and practice characteristics. Secondary and subgroup analyses investigated robustness.ResultsOur sample included 262,996 patient/year observations representing 54,085 unique patients who had, or were at risk of, CVD, from 70 practices. There was a strong decreasing secular trend in CVD-related hospitalizations but no statistically significant effect of IDOCC. Relative to patients in the control condition, patients in the intervention condition were estimated to have 4 % lower odds of CVD-related hospitalizations (adjOR = 0.96, 99 % CI 0.83 to 1.11). The nonsignificant result persisted across robustness analyses.ConclusionsClinical outcomes from administrative databases were examined to form a more complete picture of the (in)effectiveness of a large-scale quality improvement intervention. IDOCC did not have a significant effect on CVD hospitalizations, suggesting that the results from the primary composite adherence score analysis were neither due to choice of outcome nor relatively short follow-up period.

Trial registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00574808","term_id":"NCT00574808"}}NCT00574808, registered on 14 December 2007.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1547-2) contains supplementary material, which is available to authorized users.     

河北省乡镇卫生院招聘执业医师项目调查与分析

目的 了解河北省乡镇卫生院招聘执业医师项目的实施现状及问题,探索农村卫生机构吸引、稳定人才的长效机制。方法 对河北省张家口等市开展的乡镇卫生院招聘执业医师项目进行调研,主要通过调阅文件资料、个人深入访谈等方式收集资料。结果 受聘执业医师的各项政策基本得到了落实,受聘执业医师在卫生院发挥了重要作用,各方对执业医师评价较高。结论 为改善项目效果,应加大项目的督导力度、为受聘执业医师制定系统的培训计划并逐步提高待遇等。     

A multicenter study of radiation doses to the eye lenses of medical staff performing non-vascular imaging and interventional radiology procedures in Japan

PurposeThis study aimed to measure the eye lens doses received by physicians and other medical staff participating in non-vascular imaging and interventional radiology procedures in Japan.Material and methodsFrom October 2014 to March 2017, 34 physicians and 29 other medical staff engaged in non-vascular imaging and interventional radiology procedures at 18 Japanese medical facilities. These professionals wore radioprotective lead glasses equipped with small, optically stimulated luminescence dosimeters and additional personal dosimeters at the neck during a 1-month monitoring period. The H_p(3) and the H_p(10) and H_p(0.07) were obtained from these devices, respectively. The monthly H_p(3), H_p(10), and H_p(0.07) for each physician and other medical staff member were then rescaled to a 12-month period to enable comparisons with the revised occupational equivalent dose limit for the eye lens.ResultsAmong physicians, the average annual H_p(3) values measured by the small luminescence dosimeters on radioprotective glasses were 25.5 ± 38.3 mSv/y (range: 0.4–166.8 mSv/y) and 9.3 ± 16.6 mSv/y (range: 0.3–82.4 mSv/y) on the left and right sides, respectively. The corresponding values for other medical staff were 3.7 ± 3.1 mSv/y (range: 0.4–10.4 mSv/y) and 3.2 ± 2.7 mSv/y (range: 0.5–11.5 mSv/y), respectively.ConclusionsThe eye lens doses incurred by physicians and other medical staff who engaged in non-vascular imaging and interventional radiology procedures in Japan were provided. Physicians should wear radioprotective glasses and use additional radioprotective devices to reduce the amount of eye lens doses they receive.     

广西壮族自治区县级医疗卫生资源配置的公平性研究

目的 对广西县级医疗卫生资源配置的公平性进行分析。方法 采用洛伦茨曲线和基尼系数等方法,从人口和地理分布对广西91个县域医疗卫生资源(床位、卫生技术人员、医生)的配置公平性进行分析。结果 广西县级医疗卫生资源中床位、卫生技术人员、医生按人口分布的基尼系数分别为0.230 3、0.239 6、0.250 4,按地理分布的基尼系数分别为0.346 1、0.353 4、
0.352 3。结论 广西县级医疗卫生资源配置的公平性较好,其中人口分布优于地理分布,床位分布优于卫生人力资源分布。广西县级医疗卫生资源配置的公平性低于广西总体水平,但优于城区医疗卫生资源的配置。应进一步加大县级医疗卫生资源的投入,不断缩小城乡差距,提高县级医疗卫生资源在人口和地理配置的公平性。     

Age differences in presentation,diagnosis pathway and management of colorectal cancer

BackgroundThe gap in survival between older and younger European cancer patients is getting wider. It is possible that cancer in the elderly is being managed or treated differently than in their younger counterparts. This study aims to explore age disparities with respect to the clinical characteristics of the tumour, diagnostic pathway and treatment of colorectal cancer patients.MethodsWe conducted a multicenter cross sectional study in 5 Spanish regions. Consecutive incident cases of CRC were identified from pathology services. Measurements: From patient interviews, hospital and primary care clinical records, we collected data on symptoms, stage, doctors investigations, time duration to diagnosis/treatment, quality of care and treatment.Results777 symptomatic cases, 154 were older than 80 years. Stage was similar by age group. General symptoms were more frequent in the eldest and abdominal symptoms in the youngest. No differences were found regarding perception of symptom seriousness and symptom disclosure between age groups as no longer duration to diagnosis or treatment was observed in the oldest groups. In primary care, only ultrasound is more frequently ordered in those <65 years. Those >80 years had a significantly higher proportion of iron testing and abdominal XR requested in hospital. We observed a high resection rate independently of age but less adjuvant chemotherapy in Stage III colon cancer, and of radiotherapy in stage II and III rectal cancer as age increases.ConclusionThere are no relevant age disparities in the CRC diagnosis process with similar stage, duration to diagnosis, investigations and surgery. However, further improvements have to be made with respect to adjuvant therapy.     

Inpatient Medical Errors Involving Glucose-Lowering Medications and Their Impact on Patients: Review of 2,598 Incidents from a Voluntary Electronic Error-Reporting Database

ObjectiveTo describe characteristics of inpatient medical errors involving hypoglycemic medications and their impact on patient care.MethodsWe conducted a cross-sectional analysis of medical errors and associated adverse events voluntarily reported by hospital employees and staff in 21 nonprofit, nonfederal health-care organizations in the United States that implemented a Web-based electronic error-reporting system (e-ERS) between August 1, 2000, and December 31, 2005. Persons reporting the errors determined the level of impact on patient care.ResultsThe median duration of e-ERS use was 3.1 years, and 2,598 inpatient error reports involved insulin or orally administered hypoglycemic agents. Nursing staff provided 59% of the reports; physicians reported < 2%. Approximately two-thirds of the errors (1,693 of 2,598) reached the patient. Errors that caused temporary harm necessitating major treatment or that caused permanent harm accounted for 1.5% of reports (40 of 2,598). Insulin was involved in 82% of reports, and orally administered hypoglycemic agents were involved in 18% of all reports (473 of 2,598). Sulfonylureas were implicated in 51.8% of reports involving oral hypoglycemic agents (9.4% of all reports).ConclusionAn e-ERS provides an accessible venue for reporting and tracking inpatient medical errors involving glucose-lowering medications. Results are limited by potential underreporting of events, particularly by physicians, and variations in the reporter perception of patient harm. (Endocr Pract. 2008;14:535-542)     

Vitamin D Deficiency Among Medical Residents and Its Relationship with Metabolic Indices

ObjectiveTo evaluate different elements of the cal- ciotropic system in a group of house staff physicians, comparing them with age, gender, and body mass index (BMI) matched controls.MethodsWe measured vitamin D, calcium, phosphorus, parathyroid hormone (PTH), glucose, insulin (estimating the insulin resistance index by the homeostatic model [HOMA]), and lipid levels in 20 medical residents and 20 age-, gender-, and BMI-matched controls. We looked for correlations between elements of the calciotropic system and metabolic indices.ResultsMedical residents and controls were similar in regard to gender distribution, weight, height, BMI, abdominal circumference, as well as systolic and diastolic blood pressure. No differences were found between the two groups in regard to low-density lipoprotein (LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol, plasma insulin levels, and HOMA-IR. Vitamin D and calcium levels were significantly lower among the medical residents (P = .001 and P = .003, respectively), whereas PTH concentrations tended to be higher. We found an inverse correlation between triglyceride concentrations and vitamin D (r = −0.31, P = .04).ConclusionVitamin D deficiency among resident physicians is frequent and could have metabolic effects. Our findings highlight the consequences of the lack of sun exposure due to occupational reasons. We recommend a higher intake of vitamin D during this period. (Endocr Pract. 2013;19:59-63)