Is the medical value of the “personal touch” being underestimated as costs are cut?

Those involved in health care planning and the possible closure of health care facilities should remember that patients must have confidence and feel secure with the health care team in order to achieve rapid recovery. Dr. Jack Rothstein, staff surgeon at a Montreal hospital that has been slated for closure, points out the medical value of personalized, attentive care delivered by community hospitals. At a time when patients are being given more responsibility for managing their own care, he argues, elements of the health care system that help achieve continuity of care and patient empowerment should be protected. The issue is important in Montreal because the government has announced plans to close seven hospitals with 1224 acute-care beds.     

Socio-Economics of Medical Care, Report of Bureau of Research and Planning

Interest in the area of medical socio-economics has largely come about due to the proliferation of social welfare programs and advances in the distribution of health services in the private sector of the economy. The increasing role of our government has also been a stimulus. With the advent of new techniques for the financing of care, a large volume of institutional literature has appeared delving into issues which range from the role of the medical profession in the evaluation of quality of medical care to the measurement of demand for and prepayment of numerous types of health care services. Since the area of medical socio-economics is not considered "pure" enough to be categorized as a discipline, the range of periodicals, government and non-government publications and books, in which data are found, is vast. This report will briefly describe some of the more important sources of data in the area of medical socio-economics. Major emphasis is given to the literature which provides current statistical data on the operational aspects of public and private programs providing health care services, and ancillary activities which affect the market for health care activities. Leading publications of governmental and other community agencies are cited to illustrate the range of materials available to the public and to the medical profession.     

THE ROLE OF GOVERNMENT IN MEDICINE

On the fundamental question of how far a government should be involved in health services, the author believes these things can appropriately be said: The government should continue to assume complete control over public health measures, and public health officials could well be permitted to invade medical services insofar as is necessary to achieve public health ends.To assist in the production of medical personnel, it is also fitting for the government to provide for increased teaching facilities, higher salaries for teachers in the medical field and scholarships for worthy students.In the area of insurance and prepayment plans, a really intelligent supervision of such devices, with the exercise of no more arbitrary governmental power than is now used by the various other regulatory commissions, is a suitable governmental function. The government''s buying policies for its wards, rather than providing direct medical services for them, should be encouraged. This would give the private practice of medicine a boost and would improve the quality of medical care. Government should encourage the regionalization of medical services with as much of the actual controls exercised at the local level as can be achieved. Private means should be utilized for the provision of these services and public means should be used for their payment when this is an obligation of the government.The problem of mass education in health matters should be tackled by government. It would be a fine thing if the medical profession and governmental agencies could agree upon delineation of their respective roles in the health field.Because further experimentation is needed before the ideal solution is found, both government and organized medicine should encourage the exploration of new approaches.     

The Primary Care Network: A New Type of HMO for Private Practice Physicians

A new type of health maintenance organization has been developed to encourage primary care physicians in private practice to become coordinators and financial managers for all medical care. Each patient chooses one internist, family or general physician, or pediatrician and must be referred by that physician for all hospital admissions and care by specialists. The primary care physician authorizes all payments from his own account for care provided to his patients. He shares any deficit or surplus remaining at the end of the year.Hospital admission rates and length of stay are lower than those of Blue Cross, with only one of three dollars paid to hospitals. The plan is providing care to 38,000 persons with 750 participating physicians in Northern California, Washington and Utah.This plan represents an attempt by physicians to control costs without government regulation.     

Disseminating the best available evidence: New challenges in public reporting of health care

As a direct benefit of the Health Care Reform Act (2010), concerted effort has been deployed to define and characterize the process by which the best available evidence for diagnosis or treatment intervention prognosis can be obtained. The science of research synthesis in health care has established the systematic research protocol by which randomized clinical trials and other clinical studies must be reviewed and compared for the level and quality of the evidence presented, as well as the consensus of the best available evidence synthesized and shared. This process of systematic review yields a reliable and valid approach in comparing different interventions and strategies to prevent, diagnose, treat and monitor health conditions in terms of efficacy, and or of effectiveness. The resulting bioinformation outcome of comparative effectiveness and efficacy research review of the available clinical data is expressed as a consensus of the best available evidence, which finds its way in evidence-based clinical practice guidelines, standards of care and eventually, in policies: hence, the acronym CEERAP (comparative effectiveness and efficacy review and policy). The methodological and the procedural criteria that determine and regulate the public reporting dissemination of this sort of bioinformation, and the extent of benefit to the patient's health literacy, which have remained a bit more elusive to this date, are investigated and discussed in this paper.     

The Outcome of Health Anxiety in Primary Care. A Two-Year Follow-up Study on Health Care Costs and Self-Rated Health

Background

Hypochondriasis is prevalent in primary care, but the diagnosis is hampered by its stigmatizing label and lack of valid diagnostic criteria. Recently, new empirically established criteria for Health anxiety were introduced. Little is known about Health anxiety''s impact on longitudinal outcome, and this study aimed to examine impact on self-rated health and health care costs.

Methodology/Principal Findings

1785 consecutive primary care patients aged 18–65 consulting their family physicians (FPs) for a new illness were followed-up for two years. A stratified subsample of 701 patients was assessed by the Schedules for Clinical Assessment in Neuropsychiatry interview. Patients with mild (N = 21) and severe Health anxiety (N = 81) and Hypochondriasis according to the DSM-IV (N = 59) were compared with a comparison group of patients who had a well-defined medical condition according to their FPs and a low score on the screening questionnaire (N = 968). Self-rated health was measured by questionnaire at index and at three, 12, and 24 months, and health care use was extracted from patient registers. Compared with the 968 patients with well-defined medical conditions, the 81 severe Health anxiety patients and the 59 DSM-IV Hypochondriasis patients continued during follow-up to manifest significantly more Health anxiety (Whiteley-7 scale). They also continued to have significantly worse self-rated functioning related to physical and mental health (component scores of the SF-36). The severe Health anxiety patients used about 41–78% more health care per year in total, both during the 3 years preceding inclusion and during follow-up, whereas the DSM-IV Hypochondriasis patients did not have statistically significantly higher total use. A poor outcome of Health anxiety was not explained by comorbid depression, anxiety disorder or well-defined medical condition. Patients with mild Health anxiety did not have a worse outcome on physical health and incurred significantly less health care costs than the group of patients with a well-defined medical condition.

Conclusions/Significance

Severe Health anxiety was found to be a disturbing and persistent condition. It is costly for the health care system and must be taken seriously, i.e. diagnosed and treated. This study supports the validity of recently introduced new criteria for Health anxiety.     

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.     

Developing core outcome sets for clinical trials: issues to consider

ABSTRACT: Selection of appropriate outcomes or domains is crucial when designing clinical trials to compare directly the effects of different interventions in ways that minimise bias. If the findings are to influence policy and practice then the chosen outcomes need to be relevant and important to key stakeholders including patients and the public, health care professionals and others making decisions about health care. There is a growing recognition that insufficient attention has been paid to the outcomes measured in clinical trials. These issues could be addressed through the development and use of an agreed standardised collection of outcomes, known as a core outcome set, which should be measured and reported, as a minimum, in all trials for a specific clinical area. Accumulating work in this area has identified the need for general guidance on the development of core outcome sets. Key issues to consider in the development of a core outcome set include its scope, the stakeholder groups to be involved, choice of consensus method and the achievement of a consensus.     

基于博弈论与激励相容理论的我国分级诊疗体系分析

目的 了解政府、大型综合医院、上级医疗机构与基层医疗机构在分级诊疗体系下的利益诉求,以推进分级诊疗体系的建立。方法 采用博弈论分析这些利益主体间的矛盾,利用激励相容理论提出建议。结果 政府投入不足,上级医疗机构不愿下沉医疗资源,基层医疗机构能力不足等问题阻碍了分级诊疗体系的推行。结论 发挥政府引领作用,加大政府投入;加强医疗机构的分工协作,合理配置医疗资源;提高基层医疗机构服务能力。     

Larger private-sector role in health care needed now,think tank warns.

The Fraser Institute, a conservative think tank based in Vancouver, has called for the establishment of a parallel private health care sector to relieve pressure on the public system, encourage the development of medical technology, stimulate the economy and create jobs. The proposal includes establishment of competition by separating the roles of purchaser and provider of health care, and the creation of a medical premium account for each Canadian that would be funded by government but apportioned by the patient.     

Measuring the quality of later life.

This paper examines quality of life as a scientific construct with a wide range of applications. The assessment of patients'' quality of life is assuming increasing importance in medicine and health care. Illnesses, diseases and their treatments can have significant impacts on such areas of functioning as mobility, mood, life satisfaction, sexuality, cognition and ability to fulfil occupational, social and family roles. The emerging quality of life construct may be viewed as a paradigm shift in outcome measurement since it shifts the focus of attention from symptoms to functioning. This holistic approach more clearly establishes the patient as the centre of attention and subsumes many of the traditional measures of outcome. Quality of life assessment is particularly relevant to ageing populations both for healthy elderly and for those who develop chronic diseases where maintenance of quality of life rather than cure may be the primary goal of treatment. This paper introduces the concept of quality of life and describes the significant difficulties in definition, measurement and interpretation that must be addressed before such measures can be used as reliable and valid indicators of disease impact and treatment outcomes. It is argued that approaches to quality of life assessment in the elderly should incorporate advances in knowledge about the psychological adaptation to ageing. Consequently, the unique perspective of the individual on his or her own quality of life must be incorporated into outcome assessments aimed at improving the quality of health care. Incorporating measures of subjective outcome such as quality of life into policy decisions on resource allocation in health care will prove one of the major challenges for health services over the next decade.     

The problematization of medical tourism: a critique of neoliberalism

The past two decades have seen the extensive privatisation and marketisation of health care in an ever reaching number of developing countries. Within this milieu, medical tourism is being promoted as a rational economic development strategy for some developing nations, and a makeshift solution to the escalating waiting lists and exorbitant costs of health care in developed nations. This paper explores the need to problematize medical tourism in order to move beyond one dimensional neoliberal discourses that have, to date, dominated the arena. In this problematization, the paper discusses a range of understandings and uses of the term 'medical tourism' and situates it within the context of the neoliberal economic development of health care internationally. Drawing on theory from critical medical anthropology and health and human rights perspectives, the paper critically analyzes the assumed independence between the medical tourism industry and local populations facing critical health issues, where social, cultural and economic inequities are widening in terms of access, cost and quality of health care. Finally, medical tourism is examined in the local context of India, critiquing the increasingly indistinct roles played by government and private sectors, whilst linking these shifts to global market forces.     

Ethical and economic aspects of noncompliance and overtreatment.

Physicians have an ethical responsibility for cost-saving within the current medical care delivery system. Noncompliance and overtreatment are among the causes of excessive health care expenses. An effective means of improving compliance and avoiding unwanted or fruitless treatment is improved physician-patient communication. Improved communication is also the most ethical means of avoiding these expenses. The educated participation of patients in treatment decisions and of the public in health policy formation is ethically and economically preferable to bureaucratic responses and user fees. The public must be made aware of the costs and limited benefits of medical treatments and of the effects of lifestyle on health. The medical encounter must become more supportive and educational. Medical school curricula must emphasize patient involvement, which must be reinforced to medical students and residents by staff physicians'' genuine concern and effort. Quality assessments and assurance should include evaluation of communication, patient satisfaction, use of follow-up and duplication of services.     

Markets and medicine: barriers to creating a "business case for quality"

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.     

Issues and Challenges in Research on the Ethics of Medical Tourism: Reflections from a Conference

The authors co-organized (Snyder and Crooks) and gave a keynote presentation at (Turner) a conference on ethical issues in medical tourism. Medical tourism involves travel across international borders with the intention of receiving medical care. This care is typically paid for out-of-pocket and is motivated by an interest in cost savings and/or avoiding wait times for care in the patient’s home country. This practice raises numerous ethical concerns, including potentially exacerbating health inequities in destination and source countries and disrupting continuity of care for patients. In this report, we synthesize conference presentations and present three lessons from the conference: 1) Medical tourism research has the potential for cross- or inter-disciplinarity but must bridge the gap between researchers trained in ethical theory and scholars unfamiliar with normative frameworks; 2) Medical tourism research must engage with empirical research from a variety of disciplines; and 3) Ethical analyses of medical tourism must incorporate both individual and population-level perspectives. While these lessons are presented in the context of research on medical tourism, we argue that they are applicable in other areas of research where global practices, such as human subject research and health worker migration, are occurring in the face of limited regulatory oversight.     

New standards,new dilemmas--reflections on managing medical mistakes

This article describes one hospital's development of a proactive, patient centered program, which emphasizes total honesty in dealing with all aspects of patient care. This process includes the full and timely disclosure of errors which affect the patient's health and well being. The article describes the process by which the medical facility identifies errors and works with healthcare providers to arrive at a consensus on the management of these errors. Included is a step by step analysis of how disclosure can be successfully accomplished.     

Medical Humanitarianism Under Atmospheric Violence: Health Professionals in the 2013 Gezi Protests in Turkey

During the 2013 Gezi protests in Turkey, volunteering health professionals provided on-site medical assistance to protesters faced with police violence characterized by the extensive use of riot control agents. This led to a government crackdown on the medical community and the criminalization of “unauthorized” first aid amidst international criticisms over violations of medical neutrality. Drawing from ethnographic observations, in-depth interviews with health care professionals, and archival research, this article ethnographically analyzes the polarized encounter between the Turkish government and medical professionals aligned with social protest. I demonstrate how the context of “atmospheric violence”—the extensive use of riot control agents like tear gas—brings about new politico-ethical spaces and dilemmas for healthcare professionals. I then analyze how Turkish health professionals framed their provision of health services to protestors in the language of medical humanitarianism, and how the state dismissed their claims to humanitarian neutrality by criminalizing emergency care. Exploring the vexed role that health workers and medical organizations played in the Gezi protests and the consequent political contestations over doctors’ ethical, professional, and political responsibilities, this article examines challenges to medical humanitarianism and neutrality at times of social protest in and beyond the Middle East.     

Translation is not enough. Interpreting in a medical setting.

Unique obstacles must be overcome when providing medical care to patients who have an incomplete command of the English language. Serious barriers to effective communication may arise at the exact point where our health care system must succeed or fail. Miscommunication, differences in attitudes about health care, and various other misunderstandings interfere with or frustrate good health care for these patients and their families. Such difficulties are best overcome by the use of a professional interpreter who can ensure good communication between patients and health care professionals. My daily experiences as a professional medical interpreter and translator in Spanish provide insights into the complexities of bilingual and bicultural communication in the hospital setting. Although the examples given relate to Hispanic patients, the lessons learned can be extended to other foreign language patients as well.     

Setting a standard for a "silent" disease: defining osteoporosis in the 1980s and 1990s

Osteoporosis, a disease of bone loss associated with aging and estrogen loss, can be crippling but is 'silent' (symptomless) prior to bone fracture. Despite its disastrous health effects, high prevalence, and enormous associated health care costs, osteoporosis lacked a universally accepted definition until 1992. In the 1980s, the development of more accurate medical imaging technologies to measure bone density spurred the medical community's need and demand for a common definition. The medical community tried, and failed, to resolve these differing definitions several times at consensus conferences and through published articles. These experts finally accepted a standard definition at an international consensus conference convened by the World Health Organization in 1992. The construction of osteoporosis as a disease of quantifiable risk diagnosed by medical imaging machines reflects contemporary trends in medicine, including the quantification of disease, the risk factor model, medical disciplinary boundaries, and global standardization of medical knowledge.     

Medical Education and Research: The Foundations of Quality Health Care

In May 1964 the Royal Commission on Health Services declared that “health research is essential to health progress”. However, since that time the means of providing adequate health care have received far less attention than have methods of payment for physicians'' services. Because medical education and research is the source from which all other health benefits flow, urgent attention must be paid to the adequate support of teacher-scientists, as set forth in the Woods, Gordon (Gundy) report. It is the numbers and quality of these men and women, more than any other factor, that will determine the shape of medical science and, hence, medical practice in Canada in the future. Expensive as it is, Canadian medicine and Canadian medical scientists must have generous support if medical care in this country is to be of high quality.