Exposure to sputum positive cases of tuberculosis in a government hospital

A retrospective study was carried out to ascertain the degree of exposure to the tubercle bacillus within Ipoh Hospital. This study reveals that, over a one year period, 92 sputum positive cases were admitted to the general wards. In 11 of these cases, drug resistance was considered to be possible. The mean time from admission to the commencement of treatment was seven days for the newly diagnosed cases. This study thus documents a significant degree of in-hospital exposure to the tubercle bacillus.

[Motivation and incentives: different perceptions of administrators and professionals. Evaluation Team of the Materno-Infantile Health Program]

OBJECTIVE

To find the views of Primary Care District managers and Health Centre (HC) professionals in Andalusia on systems of motivation and incentive in use in this autonomous community.

DESIGN

A descriptive study which uses qualitative and quantitative methodology.

SETTING

Primary Care districts and Health Centres in Andalusia.

PARTICIPANTS

Primary Care district managers (51) and HC professionals (91).

MATERIAL AND METHODS

Information-gathering: self-administered questionnaire (managers) and focus groups (professionals).

ANALYTICAL TECHNIQUES

Non-parametric tests to compare means and analysis of contents of discourse. Field-work. July 1994 and February 1995.

RESULTS

55% of the district managers thought that the incentive systems in use were inadequate and insufficient. Enabling professionals to be trained is the main motivating and incentive mechanism in place. Variable productivity was the next most common mechanism. However, variable productivity, in the view of the professionals, was the main demotivating factor of recent years. Professionals thought that the economic rewards of the incentives system were slight, the target variables were unsuitable, there were no objective evaluation mechanisms and the economic differences between the incentives earned by managers and professionals were too great.

CONCLUSIONS

The District managers indicated that improvements in the incentives systems used are needed. The HC professionals affirmed that the Andalusian incentives system has demotivated Primary Care teams and has had little effect on orienting professional practice.

Advance directives in end-stage renal disease inherently involve family and staff

Advance directives (ADs) have a pivotal role in the practice of clinical nephrology. The following discussion reviews our own viewpoint, drawing on the present literature and on many case anecdotes from our own practice. The review focuses on (1) the intrinsic value of ADs; (2) the impact of family and staff on clinical outcome in general; (3) family relationships and medical decision-making, especially in the area of ADs; (4) the importance of communication within families and between families and staff, as characterized in "family meetings"; and (5) the power of reconciliation when family members and staff "let go." In the final analysis, ADs present the opportunity for approaching medical decision making in a manner that can lessen the stress of making difficult decisions for the patient and even promote peace of mind for all concerned family and staff.

Satisfaction of residents and families in long-term care: III. Dissemination of results

Dissemination of new information to caregivers in ways that enhance the care they deliver is central to quality improvement in health care. This article describes several strategies that have been employed in one long-term care setting and discusses evidence of their success.

[Patterns of utilization of external employee assistance program--analysis of employees who have their psychiatrists]

The purpose of this paper is to clarify some patterns of utilization of an external employee assistance program (EAP) we have conducted for other public and private facilities in the Tokyo Kenbikyoin Foundation between April, 1986 and December, 1996. The subjects were 26 men and 12 women in 7 facilities under the following conditions: (1) Employees who have already had their own psychiatrists at the first interview of the external EAP; (2) Facilities utilize the EAP for two or more employees who met the first criterion. As a result, utilization patterns differed depending on medical staff's attitude toward the external EAP. There was a significant difference according to sex. The rate for men was 54% in worksites where medical staff understood this external program (worksite A1) and 93% in worksites where they did not (worksite A2-3, B). As to expectations for the program, there were more consultations for organizational measurements (63%) in worksite A1, while less organizational matters (27%) and more personal complains about their psychiatrists in the worksite A2-3, and B. These results suggest that the involvement of medical staff is the key to utilizing the external EAP effectively.

Patient's view of dialysis care: development of a taxonomy and rating of importance of different aspects of care. CHOICE study. Choices for Healthy Outcomes in Caring for ESRD

Quality assessment efforts to enhance public accountability in dialysis care and to support provider efforts to improve care have lacked patient input. To develop brief patient evaluation or satisfaction surveys suitable for busy clinical settings, knowing patients' priorities can be helpful in deciding which aspects of care should be tracked. We conducted a study to identify salient attributes of dialysis care and to rank the importance of these attributes from the perspective of dialysis patients. We analyzed the content of patient focus group transcripts to characterize dialysis care from the patients' perspective. We then surveyed 86 patients to determine how patients would rank the importance of each aspect to quality of dialysis care. The 18 broad aspects of care identified in the focus group included: (1) care provided by nephrologists, (2) care provided by other physicians (nonnephrologists), (3) care provided by dialysis center nurses, (4) care provided by social workers and psychologists, (5) care provided by dieticians, (6) clergy, (7) care provided by technicians and physician assistants/nurse practitioners, (8) care provided by dialysis center staff in general, (9) supplies, (10) treatment choice and effectiveness, (11) patient education and training, (12) self-care, (13) dialysis machines, (14) unit environment and policies, (15) cost containment, (16) billing, (17) cost of care, and (18) health outcomes. Items ranked in the top 10 by both groups of patients included issues related to nephrologists, other doctors, nurses, and patient education and training. Compared with hemodialysis patients, peritoneal dialysis patients gave higher ratings to hospital doctors' and nurses' attention to cleanliness when working with access sites, how correct the nephrologist's instructions to patients are, whether emergency room doctors check with nephrologists, the amount of information patients get about their diet, and how well nurses answer patients' questions. Patients value certain aspects of dialysis care highly, and these aspects differed in some respects for the relatively small number of hemodialysis and peritoneal dialysis patients studied. Construction of brief questionnaires for quality assessment and assurance requires thoughtful consideration of what questions to include. Knowing patients' priorities regarding the most important aspects of care that have high potential for dissatisfaction may be helpful to continuous quality improvement of end-stage renal disease care.

Integrating alternative providers into managed care: a case study

Alternative medical techniques have become extremely popular, particularly in the western United States. Washington State recently enacted a law requiring certain health plans to include alternative providers on their physician panels. The author describes the efforts of one MCO to comply.

Determining the optimal physician mix in health maintenance organizations

Described is a simulation model for forecasting the appropriate mix of physicians needed to meet health service demands of patients in managed health care organizations. The model can be used by executives of managed health care organizations to plan for physician staffing levels by specialty. Uncertainties such as changes in the population size served by the managed health care organization, new developments in health care delivery technologies and changing attitudes of the population regarding healthier lifestyles are considered in this model. Use of the model is illustrated in an example.

Personal use of drug samples by physicians and office staff

CONTEXT

Pharmaceutical samples are commonly used in ambulatory care settings. There is limited research on their use or impact on health care providers and patients.

OBJECTIVE

To determine the extent of personal use of drug samples over a 1-year period by physicians and medical office staff.

DESIGN, SUBJECTS, AND SETTING

An anonymous cross-sectional survey of all physicians, resident physicians, nursing staff, and office staff in a family practice residency.

MAIN OUTCOME MEASURE

Quantity of drug samples taken for personal or family use.

RESULTS

Of 55 surveys issued, 53 (96%) were returned. A total of 230 separate drug samples were reported taken in amounts ranging from 1 dose to greater than 1 month's supply. Two respondents reported no use of drug samples, while 4 respondents reported taking more than 10 different samples.

CONCLUSION

Drug samples are commonly taken by physicians and office staff for personal and family use. The ethical implications of this practice warrant further discussion.

Has managed care lost its soul?

Competition has transformed managed care from social movement to corporate colossus. In fact, the earliest health plans were founded with far more idealistic goals than cutting corporate America's health care tab. Here's why that shift troubles many managed care pioneers.

Medical management committees promote quality and cost-effective managed care

MedSpan, a managed care organization, believes it should provide physicians with maximum input regarding utilization management and practice guidelines. This has been accomplished through nine committees, all of which report to a Medical Management/Quality Management Committee. This committee structure has allowed MedSpan to avoid the unilateral imposition of guidelines and has enhanced the quality of care and service while decreasing utilization and reducing costs. Examples of specific physician committee actions are included in this article.