The presence of ethics programs in critical access hospitals

The purpose of this study was to assess the presence of ethics committees in rural critical access hospitals across the United States. Several studies have investigated the presence of ethics committees in rural health care facilities. The limitation of these studies is in the definition of 'rural hospital' and a regional or state focus. These limitations have created large variations in the study findings. In this nation-wide study we used the criteria of a critical access hospital (CAH), as defined by the Medicare Rural Hospital Flexibility Program (Flex Program, 2007), to bring consistency and clarity to the assessment of the presence of ethics committees in rural hospitals. The Flex Monitoring Team conducted a national telephone survey of 381 CAH administrators throughout the United States. The survey covered a wide variety of questions concerning hospitals' community benefit, impact activities, and whether the hospital had a formally established an ethics committee. About 230 (60%) of the respondents indicated they had a formally established ethics committee or ethics consultation program at their CAH. The prevalence of ethics committees declined as the CAH location became increasingly rural along a rural-urban continuum. Unlike CAHs, all rural Department of Veterans Affairs Medical Centers have ethics committees. The results of this study provide an understanding of the limited presence of ethics committee in rural America and the need to consider new approaches for providing ethics assistance. A virtual ethics committee network may be the most efficient and effective way of providing rural hospitals access to a knowledgeable ethics committee or consultant.

Preventing ethics conflicts and improving healthcare quality through system redesign

BACKGROUND

Ethics and quality care are common drivers for healthcare organisations. Both are based on ethics principles that are the foundation for quality, and are synergistic with the Institute of Medicine's six quality aims. This paper describes the relationship between ethics principles and the goals of improving quality, safety and value. It demonstrates how healthcare staff, quality improvement professionals and ethics committee members could apply a quality improvement framework to address and prevent ethics issues.

DISCUSSION

Recurring ethics issues can have a detrimental impact on both the quality of patient care and the culture of a healthcare organisation. Clinical staff and ethics committee members traditionally respond to ethics issues using a reactive approach. Despite nascent interest in a system-oriented preventive approach to ethics issues, there is limited practical advice for ethics committee members regarding how to specifically implement a system redesign strategy. Using an illustrative case study, the authors demonstrate how to apply a recognised quality improvement framework, which focuses on clinical microsystems, to manage and decrease ethics issues--therefore enhancing the organisation's quality of care.

CONCLUSION

An important step in enhancing quality and ethics aims would be for the organisation's staff, including quality improvement professionals and ethics committee members, to collaborate in fostering system redesign. The authors' aim is not to examine in detail a specific quality improvement approach or method; rather, they wish to highlight the synergy they believe exists between quality improvement efforts and organisational ethics issues.

Ethical issues arising from variation in health services utilization at the end of life

Research on health services delivery, particularly at the end of life, has demonstrated that more care does not necessarily lead to better technical quality, patient satisfaction, or outcomes. These findings raise three ethical issues: (1) justice in the allocation of scarce resources across health service areas; (2) nonmaleficence in the provision of appropriate amounts of care to patients; and (3) transparency about local healthcare practice so patients can make enlightened decisions about healthcare choices. We conclude that in this era of healthcare accountability, managers and clinicians can use these ethical principles to drive change in the process of providing more efficient, more effective, and more patient-centered care, especially at the end of life.

Chemotherapy, within-host ecology and the fitness of drug-resistant malaria parasites

A major determinant of the rate at which drug-resistant malaria parasites spread through a population is the ecology of resistant and sensitive parasites sharing the same host. Drug treatment can significantly alter this ecology by removing the drug-sensitive parasites, leading to competitive release of resistant parasites. Here, we test the hypothesis that the spread of resistance can be slowed by reducing drug treatment and hence restricting competitive release. Using the rodent malaria model Plasmodium chabaudi, we found that low-dose chemotherapy did reduce competitive release. A higher drug dose regimen exerted stronger positive selection on resistant parasites for no detectable clinical gain. We estimated instantaneous selection coefficients throughout the course of replicate infections to analyze the temporal pattern of the strength and direction of within-host selection. The strength of selection on resistance varied through the course of infections, even in untreated infections, but increased immediately following drug treatment, particularly in the high-dose groups. Resistance remained under positive selection for much longer than expected from the half life of the drug. Although there are many differences between mice and people, our data do raise the question whether the aggressive treatment regimens aimed at complete parasite clearance are the best resistance-management strategies for humans.

Coexistence mechanisms and the paradox of the plankton: quantifying selection from noisy data

Many species of phytoplankton typically co-occur within a single lake, as do many zooplankton species (the "paradox of the plankton"). Long-term co-occurrence suggests stable coexistence. Coexistence requires that species be equally "fit" on average. Coexistence mechanisms can equalize species' long-term average fitnesses by reducing fitness differences to low levels at all times, and by causing species' relative fitness to fluctuate over time, thereby reducing differences in time-averaged fitness. We use recently developed time series analysis techniques drawn from population genetics to estimate the strength of net selection (time-averaged selection over a year) and fluctuating selection (an index of the variation in selection throughout the year) in natural plankton communities. Analysis of 99 annual time series of zooplankton species dynamics and 49 algal time series reveals that within-year net selection generally is statistically significant but ecologically weak. Rates of net selection are -10 times faster in laboratory competition experiments than in nature, indicating that natural coexistence mechanisms are strong. Most species experience significant fluctuating selection, indicating that fluctuation-dependent mechanisms may contribute to coexistence. Within-year net selection increases with enrichment, implying that among-year coexistence mechanisms such as trade-offs between competitive ability and resting egg production are especially important at high enrichment. Fluctuating selection also increases with enrichment but is independent of the temporal variance of key abiotic factors, suggesting that fluctuating selection does not emerge solely from variation in abiotic conditions, as hypothesized by Hutchinson. Nor does fluctuating selection vary among lake-years because more variable abiotic conditions comprise stronger perturbations to which species exhibit frequency-dependent responses, since models of this mechanism fail to reproduce observed patterns of fluctuating selection. Instead, fluctuating selection may arise from internally generated fluctuations in relative fitness, as predicted by models of fluctuation-dependent coexistence mechanisms. Our results place novel constraints on hypotheses proposed to explain the paradox of the plankton.

Small-amplitude cycles emerge from stage-structured interactions in Daphnia-algal systems

A long-standing issue in ecology is reconciling the apparent stability of many populations with robust predictions of large-amplitude population cycles from general theory on consumer-resource interactions. Even when consumers are decoupled from dynamic resources, large-amplitude cycles can theoretically emerge from delayed feedback processes found in many consumers. Here we show that resource-dependent mortality and a dynamic developmental delay in consumers produces a new type of small-amplitude cycle that coexists with large-amplitude fluctuations in coupled consumer-resource systems. A distinctive characteristic of the small-amplitude cycles is slow juvenile development for consumers, leading to a developmental delay that is longer than the cycle period. By contrast, the period exceeds the delay in large-amplitude cycles. These theoretical predictions may explain previous empirical results on coexisting attractors found in Daphnia-algal systems. To test this, we used bioassay experiments that measure the growth rates of individuals in populations exhibiting each type of cycle. The results were consistent with predictions. Together, the new theory and experiments establish that two very general features of consumers--a resource-dependent juvenile stage duration and resource-dependent mortality--combine to produce small-amplitude resource-consumer cycles. This phenomenon may contribute to the prevalence of small-amplitude fluctuations in many other consumer-resource populations.

The organizational costs of ethical conflicts

Ethical conflicts are a common phenomenon in today's healthcare settings. As healthcare executives focus on balancing quality care and cost containment, recognizing the costs associated with ethical conflicts is only logical. In this article, we present five case vignettes to identify several general cost categories related to ethical conflicts, including operational costs, legal costs, and marketing and public relations costs. In each of these cost categories, the associated direct, indirect, and long-term costs of the ethical conflict are explored as well. Our analysis suggests that organizations have, in addition to philosophical reasons, financial incentives to focus on decreasing the occurrence of ethical conflicts. The cost categories affected by ethical conflicts are not insignificant. Such conflicts can affect staff morale and lower the organization's overall culture and profit margin. Therefore, organizations should develop mechanisms and strategies for decreasing and possibly preventing ethical conflicts. The strategies suggested in this article seek to shift the organization's focus when dealing with conflicts, from just reacting to moving upstream-that is, understanding the root causes of ethical conflicts and employing approaches designed to reduce their occurrence and associated costs. Such an effort has the potential to enhance the organization's overall culture and ultimately lead to organizational success.

Putting "rural" into psychiatry residency training programs

OBJECTIVE

Evidence indicates disparities in the number of psychiatrists practicing in rural America compared to urban areas suggesting the need for a greater emphasis on rural psychiatry in residency training programs. The authors offer suggestions for integrating a rural focus in psychiatry residency training to foster greater competency and interest in rural psychiatry.

METHODS

The authors surveyed the limited rural psychiatry training and the more extensive family medicine rural residency literature to review efforts to develop rural focused training curricula.

RESULTS

Many factors in the rural environment influence mental health care, including overlapping professional-patient relationships, caregiver isolation and stress, limited availability and access to mental health resources, disease stigma, and economic and health status. To enhance both an interest in and the quality of the training for a rural practice, the authors suggest three levels of training for integrating rural factors into psychiatry programs from a basic didactic understanding of the contextual issues affecting rural psychiatry, to creating rural clinical experiences and preceptors, to developing a rural psychiatry fellowship.

CONCLUSIONS

Providing trainees with an understanding of the rural mental health issues and experiences might contribute to trainees' selecting rural practices and enhance the rural competency of psychiatrists.