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1.
In our health jurisdiction the proportion of elderly people is more than double the national average, and there is a severe shortage of both home care services and long-term care beds. To help the many elderly housebound people without primary medical care we initiated a medical services home care program. The goals were patient identification, clinical assessment, medical and social stabilization, matching of the housebound patient with a nearby family physician willing and able to provide home care and provision of a backup service to the physician for consultation and help in arranging admission to hospital if necessary. In the program''s first 2 years 105 patients were enrolled; the average age was 78.9 years. More than 50% were widowed, single, separated or divorced, over 25% lived alone, and more than 40% had no children living in the city. In almost one-third of the cases there had never been a primary care physician, and in another third the physician refused to do home visits. Before becoming housebound 15% had been seeing only specialists. Each patient had an average of 3.2 active medical problems and was functionally quite dependent. Thirty-five of the patients were surveyed after 1 year: 24 (69%) were still at home, and only 1 (3%) was in a long-term care institution; 83% were satisfied with the care provided, and 79% felt secure that their health needs were being met. One-third of the patients or their families said that it was not easy to reach the physician when necessary. We recommend that programs similar to ours be set up in health jurisdictions with a high proportion of elderly people. To recruit and retain cooperative physicians hospital geriatric services must be willing to provide educational, consultative and administrative support. 相似文献
2.
《The Western journal of medicine》1962,97(2):128-129
The Consumer Price Index (CPI) of the Bureau of Labor Statistics is an index which measures the price changes of 300 goods and services. Among these 300 items are several which reflect price changes for selected health care and medical care services. These comprise the medical care index and physician fee index, depending on what services are being measured.The Physician Fee Index is based upon charges for five procedures rendered by physicians: Appendectomy, tonsillectomy, obstetrical delivery, home visits and office visits.Although the CPI takes into account quality changes in the prices for various goods, it is unable to do so for services, particularly physicians'' services.The difficulty in measuring the “cost” of quality of medical care overstates price increases in the physician fee and medical care indexes. 相似文献
3.
Rebecca Kershnar Charlene Hooper Marji Gold Errol R. Norwitz Jessica L. Illuzzi 《The Yale journal of biology and medicine》2009,82(4):129-141
Purpose: Several studies have documented a deficiency in the
delivery of preventive services to adolescents during physician visits in the
United States. This study sought to assess and compare pediatric, family
medicine (FM), and obstetrics and gynecology (OB/GYN) resident perceptions of
their responsibility, training, and experience with providing comprehensive
health care services to adolescents.Methods: A 57-item, close-ended survey was designed and administered
to assess resident perceptions of the scope of their practice, training, and
experience with providing adolescent health care across a series of health care
categories.Results: Of the 87 respondents (31 OB/GYN, 29 FM, and 27 pediatric),
most residents from all three fields felt that the full range of adolescent
preventive and clinical services represented in the survey fell under their
scope of practice. Residents from all three fields need more training and
experience with mental health issues, referring teenagers to substance abuse
treatment programs, and addressing physical and sexual abuse. In addition,
OB-GYN residents reported deficiencies in training and experience regarding
several preventive counseling and general health services, while pediatric
residents reported deficiencies in training and experience regarding sexual
health services.Conclusions: Our results indicate that at this time, residents from
these three specialties are not optimally prepared to provide the full range of
recommended preventive and clinical services to adolescents. 相似文献
4.
K. Stronks A. M. Strijbis J. F. Wendte L. J. Gunning-Schepers 《BMJ (Clinical research ed.)》1997,315(7100):92-96
OBJECTIVE: To explore the arguments underlying the choices of patients, the public, general practitioners, specialists, and health insurers regarding priorities in health care. DESIGN: A qualitative analysis of data gathered in a series of panels. Members were asked to economise on the publicly funded healthcare budget, exemplified by 10 services. RESULTS: From a medical point of view, both panels of healthcare professionals thought most services were necessary. The general practitioners tried to achieve the budget cuts by limiting access to services to those most in need of them or those who cannot afford to pay for them. The specialists emphasised the possibilities of reducing costs by increasing the efficiency within services and preventing inappropriate utilisation. The patients mainly economised by limiting universal access to preventive and acute services. The "public" panels excluded services that are relatively inexpensive for individual patients. Moreover, they emphasised the individual''s own responsibility for health behaviour and the costs of health care, resulting in the choice for copayments. The health insurers emphasised the importance of including services that relate to a risk only, as well as feasibility aspects. CONCLUSIONS: There were substantial differences in the way the different groups approached the issue of what should be included in the basic package. Healthcare professionals seem to be most aware of the importance of maintaining equal access for everyone in need of health care. 相似文献
5.
Raluca Ionescu-Ittu Jane McCusker Antonio Ciampi Alain-Michel Vadeboncoeur Danièle Roberge Danielle Larouche Josée Verdon Raynald Pineault 《CMAJ》2007,177(11):1362-1368
Background
People aged 65 years or more represent a growing group of emergency department users. We investigated whether characteristics of primary care (accessibility and continuity) are associated with emergency department use by elderly people in both urban and rural areas.Methods
We conducted a cross-sectional study using information for a random sample of 95 173 people aged 65 years or more drawn from provincial administrative databases in Quebec for 2000 and 2001. We obtained data on the patients'' age, sex, comorbidity, rate of emergency department use (number of days on which a visit was made to an amergency department per 1000 days at risk [i.e., alive and not in hospital] during the 2-year study period), use of hospital and ambulatory physician services, residence (urban v. rural), socioeconomic status, access (physician: population ratio, presence of primary physician) and continuity of primary care.Results
After adjusting for age, sex and comorbidity, we found that an increased rate of emergency department use was associated with lack of a primary physician (adjusted rate ratio [RR] 1.45, 95% confidence interval [CI] 1.41–1.49) and low or medium (v. high) levels of continuity of care with a primary physician (adjusted RR 1.46, 95% CI 1.44–1.48, and 1.27, 95% CI 1.25–1.29, respectively). Other significant predictors of increased use of emergency department services were residence in a rural area, low socioeconomic status and residence in a region with a higher physician:population ratio. Among the patients who had a primary physician, continuity of care had a stronger protective effect in urban than in rural areas.Interpretation
Having a primary physician and greater continuity of care with this physician are factors associated with decreased emergency department use by elderly people, particularly those living in urban areas.Canada is reforming its health care system, with primary care as a major focus.1 The population of Canadians aged 65 years or older is expected to double by 20262 and already accounts for the largest share of total health care expenditures.3 Thus, it is important to evaluate primary care services in this population. Because the emergency department often acts as a safety net for patients receiving inadequate primary care,4 emergency department use may be an important indicator of the adequacy of primary care services.The main determinants of emergency department use by elderly people are the severity and the nature of the medical needs of the patient (overall and specific comorbidities).5 After adjustment for need, increased access to and continuity of primary care may also be associated with lower emergency department use.5 However, most studies that investigated the impact of access and continuity of primary care were carried out in the United States, where the health care system is fundamentally different from Canada''s.5–8 Furthermore, most of these studies used self- reported measures of access and continuity of primary care.5,7,9We sought to identify determinants of emergency department use in a population-based sample of elderly people in Quebec, with particular focus on measures of access to and continuity of primary care. Access was defined by 2 measures: (a) presence of a primary physician and (b) physician: population ratio. Relational continuity was defined as the proportion of primary care visits with the primary physician.10,11 Finally, because primary care services in Quebec are organized differently in urban and rural areas,12 we also compared the association between emergency department use and continuity of care for urban and rural areas. 相似文献6.
A focus on the primary care workforce is critical when discussing plans to address the fractured United States health care system. However, we must first address the primary care physician shortage crisis when planning for health care reform which focuses on increasing access to the US population. Initial strategies may include improving reimbursement rates for primary care services, incentivizing medical schools in making primary care training a priority, and developing robust loan-forgiveness programs for those who enter and work in primary care specialties. Planning with congressional representatives about these elements will better ensure sustainable health reform efforts are implemented. 相似文献
7.
The continued escalation in health care spending has caused money to become an increasingly limited resource, which may eventually affect the ability of health professionals to provide complete health care services. Health care payers have stressed efficiency and the appropriateness of health care measures and are putting greater financial pressures on health professionals by making them more accountable for services provided. Hospitals and physicians must take a more active role in monitoring health care delivery and work together to improve performance efficiency. Efficiency can be gained through a comprehensive program that emphasizes high-quality care and the effective use of health care resources. The Health Resource Management Program is a model for carrying out this function that integrates data analysis and physician input and education. 相似文献
8.
Background
Large state tobacco control programs have been shown to reduce smoking and would be expected to affect health care costs. We investigate the effect of California''s large-scale tobacco control program on aggregate personal health care expenditures in the state.Methods and Findings
Cointegrating regressions were used to predict (1) the difference in per capita cigarette consumption between California and 38 control states as a function of the difference in cumulative expenditures of the California and control state tobacco control programs, and (2) the relationship between the difference in cigarette consumption and the difference in per capita personal health expenditures between the control states and California between 1980 and 2004. Between 1989 (when it started) and 2004, the California program was associated with $86 billion (2004 US dollars) (95% confidence interval [CI] $28 billion to $151 billion) lower health care expenditures than would have been expected without the program. This reduction grew over time, reaching 7.3% (95% CI 2.7%–12.1%) of total health care expenditures in 2004.Conclusions
A strong tobacco control program is not only associated with reduced smoking, but also with reductions in health care expenditures. 相似文献9.
J S Yudkin 《BMJ (Clinical research ed.)》1978,2(6146):1212-1215
The health plans of the Tower Hamlets district management team were studied to determine what effects the report of the Resource Allocation Working Party and the White Paper "Priorities in the Health and Social Services" have had on resource allocation in a teaching district. The study showed that at present acute services are allocated a greater proportion of the district budget than occurs nationally, while geriatrics, mental health, and community services receive proportionately less. In the next three years spending on acute services is expected to decrease, while spending on geriatric facilities and community services will increase. Nevertheless, cuts in acute services will take place mainly through a reduction in the number of beds serving a community function, concentrating all acute services in the teaching hospital. Services to the district might be better maintained by creating a community hospital to meet the needs of patients who would otherwise need to be accommodated in acute beds with unnecessarily expensive support services. 相似文献
10.
Charlotte Gray 《CMAJ》1995,153(10):1498-1500
Alberta has probably made the strongest efforts of any province to reduce its health care costs. Leading the opposition to the cuts is an organization called the Friends of Medicare, a motley mix of underfinanced public-interest groups that is fighting to stop the province from sliding toward a two-tier health care system. “Alberta is dragging the rest of the country down to a two-tier system,” says Dr. Hubert Kammerer, a family physician who serves as a spokesperson for the organization. He warns that many Albertans worry that their health care system is deteriorating. 相似文献
11.
David Wilson 《PLoS medicine》2015,12(6)
There is evidence that HIV prevention programs for sex workers, especially female sex workers, are cost-effective in several contexts, including many western countries, Thailand, India, the Democratic Republic of Congo, Kenya, and Zimbabwe. The evidence that sex worker HIV prevention programs work must not inspire complacency but rather a renewed effort to expand, intensify, and maximize their impact. The PLOS Collection “Focus on Delivery and Scale: Achieving HIV Impact with Sex Workers” highlights major challenges to scaling-up sex worker HIV prevention programs, noting the following: sex worker HIV prevention programs are insufficiently guided by understanding of epidemic transmission dynamics, situation analyses, and programmatic mapping; sex worker HIV and sexually transmitted infection services receive limited domestic financing in many countries; many sex worker HIV prevention programs are inadequately codified to ensure consistency and quality; and many sex worker HIV prevention programs have not evolved adequately to address informal sex workers, male and transgender sex workers, and mobile- and internet-based sex workers. Based on the wider collection of papers, this article presents three major clusters of recommendations: (i) HIV programs focused on sex workers should be prioritized, developed, and implemented based on robust evidence; (ii) national political will and increased funding are needed to increase coverage of effective sex worker HIV prevention programs in low and middle income countries; and (iii) comprehensive, integrated, and rapidly evolving HIV programs are needed to ensure equitable access to health services for individuals involved in all forms of sex work.
Summary Points
- HIV prevention programs for sex workers, especially female sex workers, are cost-effective.
- There are opportunities to further increase the impact of HIV prevention programs for sex workers and to adapt interventions to a changing context.
- Many sex worker HIV prevention programs are insufficiently guided by understanding of epidemic transmission dynamics, situation analyses, and programmatic mapping; receive limited domestic financing in many countries; are inadequately codified to ensure consistency and quality; and have not evolved adequately to address informal sex workers, male and transgender sex workers, and mobile and internet-based sex workers.
- We recommend increasing our understanding of HIV epidemic transmission dynamics, improving situation analyses and programmatic mapping, increasing domestic financing for sex worker HIV prevention programs where feasible, delivering well-codified, comprehensive programs using “Science of Delivery” principles and developing more effective models to reach informal sex workers, male and transgender sex workers, and mobile and internet-based sex workers.
- Given their marginalization, concerted efforts must be made to ensure sex workers have equitable access to HIV prevention, care, and treatment services, as well as wider health services, particularly for STIs, mental health, and addictions.
12.
13.
The current proliferation of proposals for health care reform makes it difficult to sort out the differences among plans and the likely outcome of different approaches to reform. The current health care system has two basic features. The first, enrollment and eligibility functions, includes how people get into the system and gain coverage for health care services. We describe 4 models, ranging from an individual, voluntary approach to a universal, tax-based model. The second, the provision of health care, includes how physician services are organized, how they are paid for, what mechanisms are in place for quality assurance, and the degree of organization and oversight of the health care system. We describe 7 models of the organization component, including the current fee-for-service system with no national health budget, managed care, salaried providers under a budget, and managed competition with and without a national health budget. These 2 components provide the building blocks for health care plans, presented as a matrix. We also evaluate several reform proposals by how they combine these 2 elements. 相似文献
14.
Dearing WP 《California medicine》1960,93(2):79-81
The role of the physician in event of natural disaster or overwhelming (perhaps nuclear) attack by an enemy is:To assist the layman in preparing to meet his own health needs in a disaster situation until organized health services can reach him. To prepare and plan for the provision of organized medical care when conditions permit. To extend his own capability to render medical care outside his normal specialty. To assist in the training of allied and professional health workers and laymen for specific mobilization assignments in health services. 相似文献
15.
W. Palmer Dearing 《The Western journal of medicine》1960,93(2):79-81
The role of the physician in event of natural disaster or overwhelming (perhaps nuclear) attack by an enemy is:To assist the layman in preparing to meet his own health needs in a disaster situation until organized health services can reach him.To prepare and plan for the provision of organized medical care when conditions permit.To extend his own capability to render medical care outside his normal specialty.To assist in the training of allied and professional health workers and laymen for specific mobilization assignments in health services. 相似文献
16.
Casalino LP 《Perspectives in biology and medicine》2003,46(1):38-51; discussion 52-4
Systematically improving the quality of medical care requires the creation and implementation of organized processes by health plans, hospitals, and physician groups. But to a considerable extent the medical market in the United States financially penalizes organizations that invest in improving quality, rather than rewarding them. This article explores the ways in which the market as presently constituted fails to reward investments in quality improvement and describes efforts newly underway to create a "business case for quality." It briefly suggests measures to that could be taken by public and private policymakers--by government as purchaser and regulator of medical care, and by large employers who in effect make policy through their health insurance purchasing decisions--to create a business case for quality. 相似文献
17.
Background
Representing approximately 0.5% of the population, transgender (trans) persons in Canada depend on family physicians for both general and transition-related care. However, physicians receive little to no training on this patient population, and trans patients are often profoundly uncomfortable and may avoid health care. This study examined factors associated with patient discomfort discussing trans health issues with a family physician in Ontario, Canada.Methods
433 trans people age 16 and over were surveyed using respondent-driven sampling for the Trans PULSE Project; 356 had a family physician. Weighted logistic regression models were fit to produce prevalence risk ratios (PRRs) via average marginal predictions, for transmasculine (n = 184) and transfeminine (n = 172) trans persons.Results
Among the 83.1% (95% CI = 77.4, 88.9) of trans Ontarians who had a family physician, approximately half reported discomfort discussing trans health issues. 37.2% of transmasculine and 38.1% of transfeminine persons reported at least one trans-specific negative experience. In unadjusted analysis, sociodemographics did not predict discomfort, but those who planned to medically transition sex, but had not begun, were more likely to report discomfort (transmasculine: PRR = 2.62 (95% CI = 1.44, 4.77); transfeminine: PRR = 1.85 (95% CI = 1.08, 3.15)). Adjusted for other factors, greater perceived physician knowledge about trans issues was associated with reduced likelihood of discomfort, and previous trans-specific negative experiences with a family physician with increased discomfort. Transfeminine persons who reported three or more types of negative experiences were 2.26 times as likely, and transmasculine persons 1.61 times as likely, to report discomfort. In adjusted analyses, sociodemographic associations differed by gender, with being previously married or having higher education associated with increased risk of discomfort among transfeminine persons, but decreased risk among transmasculine persons.Conclusions
Within this transgender population, discomfort in discussing trans health issues with a family physician was common, presenting a barrier to accessing primary care despite having a regular family physician and “universal” health insurance. 相似文献18.
Background
In the wake of a national economic downturn, the state of California, in 2009–2010, implemented budget cuts that eliminated state funding of HIV prevention and testing. To mitigate the effect of these cuts remaining federal funds were redirected. This analysis estimates the impact of these budget cuts and reallocation of resources on HIV transmission and associated HIV treatment costs.Methods and Findings
We estimated the effect of the budget cuts and reallocation for California county health departments (excluding Los Angeles and San Francisco) on the number of individuals living with or at-risk for HIV who received HIV prevention services. We used a Bernoulli model to estimate the number of new infections that would occur each year as a result of the changes, and assigned lifetime treatment costs to those new infections. We explored the effect of redirecting federal funds to more cost-effective programs, as well as the potential effect of allocating funds proportionately by transmission category. We estimated that cutting HIV prevention resulted in 55 new infections that were associated with $20 million in lifetime treatment costs. The redirection of federal funds to more cost-effective programs averted 15 HIV infections. If HIV prevention funding were allocated proportionately to transmission categories, we estimated that HIV infections could be reduced below the number that occurred annually before the state budget cuts.Conclusions
Reducing funding for HIV prevention may result in short-term savings at the expense of additional HIV infections and increased HIV treatment costs. Existing HIV prevention funds would likely have a greater impact on the epidemic if they were allocated to the more cost-effective programs and the populations most likely to acquire and transmit the infection. 相似文献19.
Although articles on studies of organized home care programs are numerous, reports of long-term effectiveness of these programs are scanty. While government spokesmen appear to advocate more widespread use of alternatives to hospitalization, there has been serious criticism of the efficiency and accomplishments of home care services. A medically oriented home care program in Saskatoon (population, less than 150 000) has grown steadily over a 16-year period and is now serving a daily average of 200 individuals. All patients have required "hospital-like care" at home and most have not ordinarily been sufficiently mobile during their time in the program to attend hospital outpatient services. Many have required "concentrated care" through daily visits of professional health personnel. The program is designed for the physically ill and disabled and is administered by the major teaching hospital in the city, although it provides services to the whole community. Over one third of the patients referred in recent years had been at home. Almost one half of the patients have undergone satisfactory rehabilitation at home. The program has also proven to be an acceptable alternative to long-term institutional care for the permanently seriously disabled, a large number of whom are elderly. The program has been able to operate at considerably less cost to the public than inpatient (hospital or institutional) services would have entailed. 相似文献
20.
Sasha Shepperd Helen Doll Robert M. Angus Mike J. Clarke Steve Iliffe Lalit Kalra Nicoletta Aimonio Ricauda Vittoria Tibaldi Andrew D. Wilson 《CMAJ》2009,180(2):175-182