The impact of a new geriatric program in a hospital for the chronically ill.

Reports of the rapidly increasing proportion of persons aged 65 years and more in Canada and the resultant need for changes in the country''s health care system prompted experimental changes in the operation and training procedures at St. Mary''s of the Lake Hospital, Kingston, Ont. Aimed at better patient care and at better education of medical house staff in geriatrics and long-term care, the revised program is permeated with the philosophy of rehabilitation. It includes full-time staff, a geriatric outpatient clinic, a day hospital, a team approach to patient care (with regular team audits), problem-oriented medical records, a formal physical medicine section with a district inpatient unit, and an intensive inservice education program. After the first year of the program patient outcome had improved and more efficient use was being made of continuing care beds because of larger numbers of patinets being discharged home after shorter stays. This may be one avenue for deceleration of our country''s dismal rate of institutionalization.     

TAX-SUPPORTED MEDICAL CARE FOR CALIFORNIA'S CHILDREN—Where Should It Be Going?

The multiplication of separate governmental agencies providing health services to California''s children, the increasing difficulties in staffing tax-supported health agencies and the recent studies of the quality of care under these programs, have all pointed to an urgent need for prompt decisions on certain basic questions about the function of tax-supported medical care for children of dependent families.Fourteen separate kinds of health services are currently provided through public funds at an annual cost to California taxpayers of $52,000,000. These funds underwrite an uncoordinated, fragmented, patchwork quilt of medical care for some 500,000 children. Coordination and integration of these services through “one door” with uniform eligibility requirements and maximum utilization of private physicians'' services that meet appropriate standards is needed now. California physicians have an urgent responsibility to provide leadership in the development of more effective and more economical organization and distribution of higher quality medical care services for California''s children dependent on public support.     

Uncompensated and undercompensated care provided by San Francisco Medical Society physicians.

Practicing physician members of the San Francisco Medical Society were surveyed regarding reimbursement rates for medical care provided to underinsured and uninsured patients. Of 394 respondents, about $51,000 per physician practice was written off as uncompensated care or services not billed for in 1985. An average of 7% of each physician''s patients was estimated to be "no-pay" or charity patients, accounting for $19,000 of this total. Almost $32,000 was reported as being uncompensated care, or that which is billed but not paid. In addition to these amounts, an average of $32,000 was reported as being discounted from the usual fee levels by government insurance programs. Extrapolating these results to the physician membership of the local medical society indicates that physicians in San Francisco may be providing as much as $81 million in uncompensated or charity care annually. These results emphasize that private practitioners are providing a significant amount of medical care at reduced or charity rates, an amount that can be expected to increase given present trends. Substantial changes are needed if the burden of providing medical care to poor and uninsured Americans is not to fall disproportionately on private providers.     

When families cannot "let go": ethical decision-making at the bedside.

Shared decision-making at the bedside is now a regular feature of medical practice. When disagreements arise between a patient and family members caregivers sometimes find themselves caught in a complex tangle of human relationships that strains monochrome ethical thinking. The patient''s expressed wishes are often compromised for the sake of the family''s needs. Conversely, a unilateral appeal for patient autonomy may prove insensitive to the hurt and the needs of the family. We describe a relatively unsuccessful attempt by a patient''s caregivers to buy time to maximize the interests of the patient and her family and discuss the way in which the family dynamics militated against the rather obvious solution of promoting the patient''s right to refuse treatment. The purpose of this article is not to evoke sympathy for health care professionals in dealing with such conflicts but rather to heighten awareness of the issues at stake and to stimulate thinking about ways and means to bring about a more favourable outcome than the one described here.     

The Potential of Medical Abortion to Reduce Maternal Mortality in Africa: What Benefits for Tanzania and Ethiopia?

Background

Unsafe abortion is estimated to account for 13% of maternal mortality globally. Medical abortion is a safe alternative.

Methods

By estimating mortality risks for unsafe and medical abortion and childbirth for Tanzania and Ethiopia, we modelled changes in maternal mortality that are achievable if unsafe abortion were replaced by medical abortion. We selected Ethiopia and Tanzania because of their high maternal mortality ratios (MMRatios) and contrasting situations regarding health care provision and abortion legislation. We focused on misoprostol-only regimens due to the drug''s low cost and accessibility. We included the impact of medical abortion on women who would otherwise choose unsafe abortion and on women with unwanted/mistimed pregnancies who would otherwise carry to term.

Results

Thousands of lives could be saved each year in each country by implementing medical abortion using misoprostol (2122 in Tanzania and 2551 in Ethiopia assuming coverage equals family planning services levels: 56% for Tanzania, 31% for Ethiopia). Changes in MMRatios would be less pronounced because the intervention would also affect national birth rates.

Conclusions

This is the first analysis of impact of medical abortion provision which takes into account additional potential users other than those currently using unsafe abortion. Thousands of women''s lives could be saved, but this may not be reflected in as substantial changes in MMRatios because of medical abortion''s demographic impact. Therefore policy makers must be aware of the inability of some traditional measures of maternal mortality to detect the real benefits offered by such an intervention.     

Problems of care in a private nursing home.

To assess problems of care in a private nursing home an observational study was carried out over two months, during which a research nurse worked as a member of the staff in a home caring for 25 patients aged 62-90. During the second month a consultant physician visited the home weekly to hold case conferences and assess each patient''s functional ability and drug regimen. Various problems in medical, nursing, and bureaucratic matters were identified--for example, staff failed to understand the appropriate response to various medical symptoms; no clear policy existed for managing pressure sores; and one patient''s anticoagulant state could not be assessed when industrial action meant that transport to take him to hospital was not available--and several changes in drug treatments were recommended. The problems that were identified were mainly due to poor communication between the home and general practitioners and hospitals and to the lack of guidance policy on common issues that arise in long term care. Such a policy could be produced by health authority staff, general practitioners, and representatives of nursing homes.     

The one child family policy: the good,the bad,and the ugly.

Rapid population growth in China during the 1950s and ''60s led to the "late, long, few" policy of the 1970s and a dramatic reduction in the total fertility rate. However, population growth remained too high for the economic targets of Deng Xiao Ping''s reforms, so the one child family policy was introduced in 1979 and has remained in force ever since. The strategy is different in urban and rural areas, and implementation varies from place to place depending on local conditions. The policy has been beneficial in terms of curbing population growth, aiding economic growth, and improving the health and welfare of women and children. On the negative side there are concerns about demographic and sex imbalance and the psychological effects for a generation of only children in the cities. The atrocities often associated with the policy, such as female infanticide, occur rarely now. China may relax the policy in the near future, probably allowing two children for everyone.     

Reductions in Inpatient Mortality following Interventions to Improve Emergency Hospital Care in Freetown,Sierra Leone

Background

The demand for high quality hospital care for children in low resource countries is not being met. This paper describes a number of strategies to improve emergency care at a children''s hospital and evaluates the impact of these on inpatient mortality. In addition, the cost-effectiveness of improving emergency care is estimated.

Methods and Findings

A team of local and international staff developed a plan to improve emergency care for children arriving at The Ola During Children''s Hospital, Freetown, Sierra Leone. Following focus group discussions, five priority areas were identified to improve emergency care; staff training, hospital layout, staff allocation, medical equipment, and medical record keeping. A team of international volunteers worked with local staff for six months to design and implement improvements in these five priority areas. The improvements were evaluated collectively rather than individually. Before the intervention, the inpatient mortality rate was 12.4%. After the intervention this improved to 5.9%. The relative risk of dying was 47% (95% CI 0.369–0.607) lower after the intervention. The estimated number of lives saved in the first two months after the intervention was 103. The total cost of the intervention was USD 29 714, the estimated cost per death averted was USD 148. There are two main limitation of the study. Firstly, the brevity of the study and secondly, the assumed homogeneity of the clinical cases that presented to the hospital before and after the intervention.

Conclusions

This study demonstarted a signficant reductuion in inpatient mortality rate after an intervention to improve emergency hospital care If the findings of this paper could be reproduced in a larger more rigorous study, improving the quality of care in hospitals would be a very cost effective strategy to save children''s lives in low resource settings.     

WHO in retreat: is it losing its influence?

WHO says it has three main functions: to set normative standards; to provide technical advice and assistance on medical matters; and to advocate changes in health policy. During its 46 year history the first two functions have been a constant and uncontroversial backbone through which WHO has earned its reputation for scientific excellence. The third function, advocacy, came to the fore with the launch of Health for All in 1977, after which WHO took a key role in influencing international health policy. WHO''s friends and critics alike now say that the organisation is losing its influence and retreating into its technical and biomedical shell. This article maps the changes in WHO''s approach over the past 46 years and considers whether fears about its loss of influence are justified.     

The Oslerian Tradition and Changing Medical Education: A Reappraisal

Although only 21 of Sir William Osler''s 45 years in academic medicine were spent in US medical schools (1884 to 1905), he played a major role in shaping modern medical education in this country. The integration of scholarship with patient care, together with the science and art of medicine, was central to Osler''s teaching and writing throughout his career. A classic generalist and a charismatic clinical teacher, he taught by example and was as concerned with the ideals of medicine as with its science and knowledge.Many changes have reshaped the content, process and concerns of American medical education since Osler''s time. Subspecialization and balkanization of medical education and practice have become dominant. Many of the important issues in medicine today do not fit neatly into the domain of any of the established specialties or medical organizations. There is now an urgent need to promote generalist attitudes in medicine, and the Oslerian tradition has much to offer in approaching today''s problems in medical education and practice.     

Medical education and society.

As health care changes under the pressures of restraint and constraint our vision of the future of medical education should be based on the medical school''s responsibility to the community. The medical school is "an academy in the community": as an academy, it fosters the highest standards in education and research; as an institution in the community, it seeks to improve public health and alleviate suffering. The author argues that to better achieve these goals medical schools need to become more responsible and responsive to the population they serve. Medical schools have been slow to accept fully the social contract by which, in return for their service to society, they enjoy special rights and benefits. This contract requires that medical educators listen to the public, talk honestly and constructively with government representatives and assess the needs and expectations of the community.     

Jehovah's Witnesses leading education drive as hospitals adjust to no blood requests.

Jehovah''s Witness representatives have visited more than 10 Canadian medical schools and 200 hospitals in an attempt to educate future and practising physicians about nonblood medicine. The trend is becoming more popular since the advent of HIV, and there are now about 100 bloodless medicine and surgery centres around the world, including 52 in the US. However, a Jehovah''s Witness spokesman says Canada is "conspicuously absent" from the list of countries that offer bloodless-medicine programs.     

What did audit achieve? Lessons from preliminary evaluation of a year's medical audit.

OBJECTIVE--To evaluate the experience of a year''s audit of care of medical inpatients. DESIGN--Audit of physicians by monthly review of two randomly selected sets of patients'' notes by 12 reviewers using a detailed questionnaire dedicated to standards of medical records and to clinical management. Data were entered into a database and summary statistics presented quarterly at audit meetings. Assessment by improvement in questionnaire scores and by interviewing physicians. SETTING--1 District general hospital. PARTICIPANTS--About 40 consultant physicians, senior registrars, and junior staff dealing with 140 inpatient records. MAIN OUTCOME MEASURES--Median scores (range 1 to 9) for each item in the questionnaire; two sets of notes were discussed monthly at "general" audit meetings and clinical management of selected common conditions at separate monthly meetings. RESULTS--A significant overall increase in median scores for questions on record keeping occurred after the start of the audit (p less than 0.01), but interobserver variation was high. The parallel audit meetings on clinical management proved to be more successful than the general audits in auditing medical care and were also considered to be more useful by junior staff. CONCLUSIONS AND ACTION--Medical audit apparently resulted in appreciable improvements in aspects of care such as clerking and record keeping. Analysis of the scores of the general audits has led to the introduction of agreed standards that can be objectively measured and are being used in a further audit, and from the results of the audits of clinical management have been developed explicit guidelines, which are being further developed for criterion based audit.     

Withholding or Withdrawing Extraordinary Life Support—Optimizing Rights and Limiting Liability

For many years physicians, ethicists and members of the legal community have attempted to minimize ambiguity and unpredictability in making decisions to withhold or withdraw extraordinary life support. Recent developments in national and California law now afford medical care providers unparalleled protection from criminal and civil liability in surrogate decision-making situations. They also reinforce the concept of patient''s rights by providing medical care consumers with new and effective mechanisms for enforcing their “right to decide,” even after they have lost decision-making capacity. A case in point is California''s new Durable Power of Attorney for Health Care, which serves as a model for other jurisdictions that do not have such legislation. Thus, the medical and legal professions, working together, can contribute immeasurably to respectful medical decision making by educating the public about these developments and by adopting policies that reinforce these rights.     

Childhood acute lymphocytic leukemia: progress and problems in treatment.

Acute lymphocytic leukemia is the most common cancer of childhood. A series of total therapy studies begun in 1962 at St. Jude Children''s Research Hospital in Memphis, Tennessee has had a dramatic impact on the survival of children with this disease. These studies have systematically examined various drug combinations and radiation therapy in an effort to cure acute lymphocytic leukemia. As a result, a once uniformly fatal condition is now curable in nearly one half of cases. In addition to improved control of the primary disease, refinements in drug treatment and in supportive care have diminished the frequency of severe infections, which may complicate aggressive therapy. Although the quality of life for the survivors so far appears generally good, treatment-induced toxic effects may impose subtle, though significant, handicaps in some cases. A combination of clinical and laboratory investigations begun in the mid-1970s is beginning to demonstrate a previously unknown heterogeneity among patients with acute lymphocytic leukemia. It is now possible to recognize a substantial minority of patients on the basis of these studies as being at "high risk" for treatment failure. For them, drastic modifications of present programs are being investigated in an attempt to improve their prognosis. For patients lacking high-risk features improvements are still needed, but changes in their treatment must be kept within the framework of what is presently successful and must address the hazard of long-term toxicity.     

The Inability of the Consumer Price Index to Measure “Cost of Quality” of Medical Care,Report of the Bureau of Research and Planning

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.     

Where is the silver lining? Anxious doctors ask.

When Nova Scotia elected a Liberal government in September 1993, a wave of optimism washed over the province''s medical community. One of their own, Dr. John Savage, was now premier, and another, Dr. Ron Stewart, was minister of health. However, anticipation soon turned to anger as Stewart took aim at physician fees and hospital costs to help reduce the province''s health care budget by $62 million. Last November, relations between him and the Medical Society of Nova Scotia (MSNS) hit bottom. In an uncharacteristically political move, the society launched an ad campaign featuring slogans such as "Death by 1000 cuts" and "Uncle Sam want me. Ron Stewart doesn''t." Four months later, the health department and the MSNS called a truce, with an agreement that many physicians consider a positive step. Today the province and its doctors are speaking again, and the medical society is working hard to help define physicians'' roles in a new, regionalized health care system. But has the mood of doctors really improved? Last spring, CMAJ interviewed a cross section of Nova Scotia physicians to find out.     

沙化土地封禁保护政策的农户满意度及影响因素分析——以甘肃省为例

农户是生态治理政策的"践行者",也是政策效果的"检验者",其满意度对政策的可持续实施至关重要。基于甘肃省沙化土地封禁保护区周边1417份农户调查数据,运用帕累托分析方法和Ordered Logit模型,就沙化土地封禁保护政策的农户满意度及影响因素展开分析。研究结果表明:沙化土地封禁保护政策的农户总体满意度介于"一般"和"满意"之间,均值为3.67("非常满意"为5);外部影响因素分析表明,政策实施效果中风沙危害削减程度、荒漠化逆转程度、家庭收入提升状况、破坏行为减少程度与农户满意度之间存在正相关性;生态变化感知中的风沙强度、水资源紧缺程度对农户满意度起负向作用,降雨(雪)次数变化、荒漠植被盖度对农户满意度起正向作用。农户内部自身因素中,家庭人均收入、耕地、政府补贴、性别、教育程度、健康状况与农户满意度均通过显著性检验。控制变量因素中地方政府治理重视程度与农户满意度呈正相关性,平原地区的农户满意度明显高于山区。从政策角度看,农户生计改善是未来沙化土地封禁保护政策成功实施的关键保障。     

NHS waiting list have been a boon for private medicine in the UK.

Health care: public, private or both? In Great Britain, about 13% of the population is covered by private health insurance, and everyone else is served by the public health care system known as the National Health Service, or NHS. Caroline Richmond, who examined the impact of private medical practice in Britain, says people become private patients for one compelling reason: to avoid the NHS''s notoriously long waiting lists for surgery. According to Professor Alan Maynard, a health care researcher, the mainstays of the private sector are the "three h''s" --hips, hernias and hemorrhoids-- along with some elective surgery, particularly in gynecology and opthalmology. Another small sector focuses on fertility regulation and cosmetic surgery. Although the levels are not monitored closely, physician consultants are not permitted to earn more than 10% of their income from private practice.