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Kinds of Health System Terms modified by Health System Selected AbstractsGeriatric Emergency Medicine and the 2006 Institute of Medicine Reports from the Committee on the Future of Emergency Care in the U.S. Health SystemACADEMIC EMERGENCY MEDICINE, Issue 12 2006Scott T. Wilber MD Abstract Three recently published Institute of Medicine reports, Hospital-Based Emergency Care: At the Breaking Point, Emergency Medical Services: At the Crossroads, and Emergency Care for Children: Growing Pains, examined the current state of emergency care in the United States. They concluded that the emergency medicine system as a whole is overburdened, underfunded, and highly fragmented. These reports did not specifically discuss the effect the aging population has on emergency care now and in the future and did not discuss special needs of older patients. This report focuses on the emergency care of older patients, with the intent to provide information that will help shape discussions on this issue. [source] Development of a Gerodontology course in Athens: a pilot studyEUROPEAN JOURNAL OF DENTAL EDUCATION, Issue 3 2006A. E. Kossioni Aim:, To describe the development of an undergraduate Gerodontology course in Athens Dental School. Background:, Because of demographic changes, undergraduate dental curricula should place appropriate emphasis on the oral care of the elderly. Therefore, the Athens Dental School Curriculum Committee authorised the development of a new Gerodontology course. Methods:, The new course was introduced in the 10th (final) semester of undergraduate studies. Teaching responsibilities were shared amongst staff from various Dental School departments and the National Health System. The course was elective and mainly didactic, consisting of seminars within the Dental School, educational visits to hospitals and geriatric day centres and elective clinical work in the comprehensive care clinic. The students evaluated the course at the end of the semester and indicated its strengths and weaknesses from their perspective. Conclusion:, The new course was generally satisfying. Based on the experience and evaluation of the first pilot year and taking into consideration the existing barriers, we plan to improve and expand educational activities, mainly including improved methods of teaching and assessment, and more clinical assignments. [source] Bon Secours Health System integrates Lean Six Sigma and Knowledge Transfer to drive clinical and operational excellenceGLOBAL BUSINESS AND ORGANIZATIONAL EXCELLENCE, Issue 6 2009H. Douglas Sears By harnessing accelerated performance improvement and rapid learning across all of its 29 facilities, Bon Secours pursues consistency, integration, quality, and transparency of patient care, even as it leverages the scale and scope of its operations for higher efficiencies. And now it's pursuing the holy grails of standardized care and a single electronic medical record for each patient. Improvement projects linked to performance gaps in balanced scorecard dashboards are executed with Lean Six Sigma methodologies and rapid-cycle improvement. Communities of Excellence then transfer improvements and replicate proven practices across facilities. This approach is helping fuel two interconnected initiatives: Clinical Transformation, the redesign of workflows,including common order sets and care plans,supported by the new ConnectCare clinical information system, which together aim to standardize 80 percent of patient care across all facilities. © 2009 Wiley Periodicals, Inc. [source] Obstetric Complications in Women with Diagnosed Mental Illness: The Relative Success of California's County Mental Health SystemHEALTH SERVICES RESEARCH, Issue 1 2010Dorothy Thornton Objective. To examine disparities in serious obstetric complications and quality of obstetric care during labor and delivery for women with and without mental illness. Data Source. Linked California hospital discharge (2000,2001), birth, fetal death, and county mental health system (CMHS) records. Study Design. This population-based, cross-sectional study of 915,568 deliveries in California, calculated adjusted odds ratios (AORs) for obstetric complication rates for women with a mental illness diagnosis (treated and not treated in the CMHS) compared with women with no mental illness diagnosis, controlling for sociodemographic, delivery hospital type, and clinical factors. Results. Compared with deliveries in the general non,mentally ill population, deliveries to women with mental illness stand a higher adjusted risk of obstetric complication: AOR=1.32 (95 percent confidence interval [CI]=1.25, 1.39) for women treated in the CMHS and AOR=1.72 (95 percent CI=1.66, 1.79) for women not treated in the CMHS. Mentally ill women treated in the CMHS are at lower risk than non-CMHS mentally ill women of experiencing conditions associated with suboptimal intrapartum care (postpartum hemorrhage, major puerperal infections) and inadequate prenatal care (acute pyelonephritis). Conclusion. Since mental disorders during pregnancy adversely affect mothers and their infants, care of the mentally ill pregnant woman by mental health and primary care providers warrants special attention. [source] Antidepressant drug prescribing among elderly subjects: a population-based studyINTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, Issue 2 2005Mauro Percudani Abstract Background The patterns of antidepressant drug prescribing have rarely been studied in large and geographically defined populations of elderly subjects. In the present study we examined the prevalence and distribution of antidepressant prescribing in Lombardy, a northern Italy region with more than one and a half million elderly inhabitants. Methods We used the Regional Administrative Database of Lombardy. This database includes all prescriptions reimbursed by the National Health System in the population living in this region. All antidepressant prescriptions dispensed to subjects aged 65 years or above during 2001 were extracted and prevalence data calculated by dividing antidepressant users by the total number of male and female residents in each age group. Results During the 12 months surveyed 153,706 subjects were dispensed one or more prescriptions of antidepressants, yielding a prevalence of use of 9.49 subjects per 100 inhabitants (95% confidence interval 9.44, 9.53). Although the proportion of chronic users slightly decreased with age, more than 35% of those older that 85 years were moderate or chronic antidepressant users. General practitioners issued the majority of antidepressant prescriptions, and most antidepressant users were also dispensed agents for medical disorders. Conclusions The very high rates of antidepressant drug prescribing detected in late life suggest the need of characterising these subjects in terms of medical and psychiatric characteristics, needs and quality of life. It also suggests the need for pragmatic clinical trials, carried out in the general practice, with the aim of assessing whether antidepressants are effective in these conditions. Copyright © 2005 John Wiley & Sons, Ltd. [source] Barriers for dental treatment of primary teeth in East and West GermanyINTERNATIONAL JOURNAL OF PAEDIATRIC DENTISTRY, Issue 2 2009CHRISTIAN H. SPLIETH Background., In many countries, restorative treatment in primary teeth is suboptimal. Aim., Thus, this study tried to detect barriers for dentists to restore primary teeth in kindergarten children (3,6 years). Design., For a representative survey, 320 dentists (184 West, 136 East Germany) were randomly selected from the dental associations' registers and asked to answer a questionnaire on their profile, their view of the National Health System, and possible barriers for restoring primary teeth. Results., The analysis (response rate 57.7%) showed that the parents were no barrier and the dentists felt the need of restoring primary teeth. In addition to the children's anxiety, the inadequate reimbursement for fillings were perceived as clear barrier. The comparison of West and East German dentists detected statistically significantly higher barriers in West Germany, where , in contrast to the German Democratic Republic , no structured training in paediatric dentistry was compulsory before unification. Only 35% of the East German dentists rated restorative treatment in 3- to 6-year-olds as stressful in contrast to 65% in West Germany, where especially male dentists found no time to treat children. Conclusion., This study reveals that dentists can also be a considerable barrier to restorative treatment in small children, especially without adequate training in dental schools. [source] An educational process to strengthen primary care nursing practices in São Paulo, BrazilINTERNATIONAL NURSING REVIEW, Issue 4 2007A.M. Chiesa rn Objective:, To describe the experience of a registered nurse (RN) training process related to the Family Health Program (FHP) developed in the city of São Paulo, Brazil. Background:, The FHP is a national, government strategy to restructure primary care services. It focuses on the family in order to understand its physical and social structure in regards to the health,illness process. In the FHP, the RN is a member of a team with the same number as medical doctors , an unprecedented situation. The FHP requires a discussion of the RNs' practice, by qualifying and empowering them with tools and knowledge. Methods:, The training process was based on Freire's approach founded on critical pedagogy in order to address the fundamental problem of inequalities in health. The first phase included workshops and the second one included a course. The workshops identified the following problems related to the RN's work: lack of tools to identify the population's needs; overload of work due to the accumulation of management and assistance activities; difficulties regarding teamwork; lack of tools to evaluate the impact of nursing interventions; lack of tools to improve the participation of the community. The course was organized to tackle these problems under five thematic headings. Results:, The RN's training process allowed the group to reflect deeply on its work. This experience led to the need for the construction of tools to intervene in the reality, mainly against social exclusion, rescuing and adapting of the knowledge accumulated in the healthcare practice, identifying settings which demand institutional solutions and engaging the RN in research groups in order to develop projects according to the complexity of the primary care services. Conclusion:, The application of the concept of equity in the health sector represented a reaction against the processes of social exclusion, starting from performance at a local level to become a reality in the accomplishments achieved by the Brazilian National Health System. This training process allowed us to evaluate that partnership, which has produced many concrete results in addressing both parts of the Inequalities in Health dilemma and which is a productive way of building up a new model of health. [source] Interview with a Quality Leader,Karen Davis, Executive Director of The Commonwealth FundJOURNAL FOR HEALTHCARE QUALITY, Issue 2 2009Lecia A. Albright Dr. Davis is a nationally recognized economist, with a distinguished career in public policy and research. Before joining the Fund, she served as chairman of the Department of Health Policy and Management at The Johns Hopkins School of Public Health, where she also held an appointment as professor of economics. She served as deputy assistant secretary for health policy in the Department of Health and Human Services from 1977 to 1980, and was the first woman to head a U.S. Public Health Service agency. Before her government career, Ms. Davis was a senior fellow at the Brookings Institution in Washington, DC; a visiting lecturer at Harvard University; and an assistant professor of economics at Rice University. A native of Oklahoma, she received her PhD in economics from Rice University, which recognized her achievements with a Distinguished Alumna Award in 1991. Ms. Davis is the recipient of the 2000 Baxter-Allegiance Foundation Prize for Health Services Research. In the spring of 2001, Ms. Davis received an honorary doctorate in human letters from John Hopkins University. In 2006, she was selected for the Academy Health Distinguished Investigator Award for significant and lasting contributions to the field of health services research in addition to the Picker Award for Excellence in the Advancement of Patient Centered Care. Ms. Davis has published a number of significant books, monographs, and articles on health and social policy issues, including the landmark books HealthCare Cost Containment, Medicare Policy, National Health Insurance: Benefits, Costs, and Consequences, and Health and the War on Poverty. She serves on the Board of Visitors of Columbia University, School of Nursing, and is on the Board of Directors of the Geisinger Health System. She was elected to the Institute of Medicine (IOM) in 1975; has served two terms on the IOM governing Council (1986,90 and 1997,2000); was a member of the IOM Committee on Redesigning Health Insurance Benefits, Payment and Performance Improvement Programs; and was awarded the Adam Yarmolinsky medal in 2007 for her contributions to the mission of the Institute of Medicine. She is a past president of the Academy Health (formerly AHSRHP) and an Academy Health distinguished fellow, a member of the Kaiser Commission on Medicaid and the Uninsured, and a former member of the Agency for Healthcare Quality and Research National Advisory Committee. She also serves on the Panel of Health Advisors for the Congressional Budget Office. [source] Fungemia Associated with Left Ventricular Assist Device SupportJOURNAL OF CARDIAC SURGERY, Issue 6 2009M.P.H., Natasha G. Bagdasarian M.D. While relatively uncommon, fungal infections present a serious concern given a high association with adverse events including death. We sought to further characterize the epidemiology of fungemias during LVAD support. Methods: Retrospective review of 292 patients receiving LVAD support from October 1996 to April 2009 at the University of Michigan Health System was done. Results: Seven cases of LVAD-associated fungemia were observed during the study period (0.1 infections/1000 days of device support). Five patients had infection with Candida species and two with Aspergillus species. The two patients with Aspergillus infection presented with disseminated disease, quickly dying of multiorgan failure, and sepsis. All five patients with Candida infections were successfully treated with systemic antifungal therapy along with transplantation in four of five patients. The fifth patient is receiving mechanical support as destination therapy. He remains on long-term suppression with high-dose fluconazole. Conclusions: Fungal infections appear to be a rare but serious complication of LVAD support. Future studies should aim to improve our understanding of risk factors for fungal infection during mechanical support, especially disseminated Aspergillus. Short-term perioperative antifungal prophylaxis with fluconazole appears to be an effective and reasonable approach to prevention. [source] Infection control nurse: a national surveyJOURNAL OF NURSING MANAGEMENT, Issue 5 2004R. Quattrin MD Aim, To study presence and activity of Infection Control Nurses (ICN) in Italian National Health System (NHS) hospitals. Background, Infection Control Nurses play an essential and evidence-based role for optimal infrastructure and essential activities of infection control and epidemiology programmes in hospitals. Methods, A survey of all Italian NHS hospitals (N = 529). Hospital health directors were asked to complete a questionnaire with a specific section on ICN presence, activities and roles played. Response rate was 87.5% (463 of 529). Results, More than 50% of hospitals (250 of 463) have an ICN: 25% (116 of 463) have at least one part-time employed ICN and 23.3% (108 of 250) have at least one ICN employed full-time. Infection Control Nurses are more common in hospitals with >250 beds (P < 0.01). Infection Control Nurses working in hospitals with >250 beds are highly active in surveillance activities, personnel education and management of study groups (P < 0.01). Conclusions, In Italian NHS hospitals ICNs have yet to become pillar figures in hospital infection control. [source] Using gabapentin to treat failed back surgery syndrome caused by epidural fibrosis: A report of 2 cases. (University of Pennsylvania Health System, School of Medicine, Pennsylvania, PA).PAIN PRACTICE, Issue 4 2001Arch Phys Med Rehabil. Failed back surgery syndrome (FBSS) is a long-lasting often disabling, and relatively frequent (5% to 10%) complication of lumdosacral spine surgery. Epidural fibrosis is among the most common causes of FBSS, and it is often recalcitrant to treatment. Repeated surgery for fibrosis has only a 30% to 35% success rate, whereas 15% to 20% of patients report worsening of their symptoms. Long-term outcome studies focusing on pharmacologic management of chronic back pain secondary to epidural fibrosis are lacking in the literature. This report presented 2 cases of severe epidural fibrosis managed successfully with gabapentin monotherapy. In both cases, functional status improved markedly and pain was significantly diminished. Gabapentin has an established, favorable safety profile and has been shown to be effective in various animal models and human studies of chronic neuropathic pain. Conclude clinicians should consider gabapentin as a pharmacological treatment alternative in the management of FBSS caused by epidural fibrosis. [source] Will Subsidising Private Health Insurance Help the Public Health System?THE ECONOMIC RECORD, Issue 242 2002Rhema Vaithianathan This paper challenges the argument that expanding private health insurance coverage in Australia will reduce the demand for public hospitals. We construct a simple model to illustrate that although a premium subsidy might expand insurance coverage, it may not reduce the demand for public health services. The reason is that, under certain conditions, government subsidies only increase insurance coverage among self,insured consumers; that is, consumers who are uninsured but purchase private health care if they fall ill. We argue that subsidising private health care rather than insurance is a more effective way of reducing the demand for public health services. [source] Integrating education into primary care quality and cost improvement at an academic medical centerTHE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS, Issue 4 2006R. Van Harrison PhD Abstract Introduction: In 1996 the University of Michigan Health System created the Guidelines Utilization, Implementation, Development, and Evaluation Studies (GUIDES) unit to improve the quality and cost-effectiveness of primary care for common medical problems. GUIDES's primary functions are to oversee the development of evidence-based, practical clinical guidelines for common medical conditions; measure and provide feedback on physicians' performance; and facilitate systemic changes to support appropriate care. Various methods are used to improve care, including evidence reviews, formal education, informal clinical "opinion leaders," feedback, reminders, and procedure changes. Twenty-four common medical conditions have been addressed through this process. More than 30 measures of clinical performance have been developed and reported. Methods: This case study describes a systematic, multifaceted program to improve the quality and cost-effectiveness of primary care. Results: Illustrative results for clinical performance are presented for 2 measures of chronic care, 2 measures of preventive care, and 2 measures of acute care. All 6 measures show general improvement in performance across years, with performance near or above the National Committee for Quality Assurance's 90th percentile for Health Plan Employer Data and Information Set measures. Discussion: A systematic approach involving all relevant components of a health system integrates the synthesis of information, education about the information and how to implement it, and addressing operational barriers. Benefits include a curriculum that is shared across faculty, residents, and medical students and more uniform quality of care that faculty model for physicians-in-training. [source] Aiming High for the U.S. Health System: A Context for Health ReformTHE JOURNAL OF LAW, MEDICINE & ETHICS, Issue 4 2008Karen Davis Policy officials often assert that the U.S. has the best health care system in the world, but a recent scorecard on U.S. health system performance finds that the U.S. achieves a score of only 65 out of a possible 100 points on key indicators of performance in five key domains: healthy lives, access, quality, equity, and efficiency, where 100 represents the best achieved performance in other countries or within the U.S. The U.S. should aim higher by adopting a set of policies that will extend affordable health insurance to all; align financial incentives for health care providers to enhance value and achieve savings; organize the health care system around the patient to ensure that care is accessible and coordinated; meet and raise benchmarks for high-quality, efficient care; and ensure accountable national leadership and public-private collaboration. The incoming president and Congress should aspire to have the best health system in the world , not just assert it , and can do so by learning from examples of excellence within the U.S. and abroad. [source] RISK ATTITUDES AND THE DEMAND FOR PRIVATE HEALTH INSURANCE: THE IMPORTANCE OF ,CAPTIVE PREFERENCES'ANNALS OF PUBLIC AND COOPERATIVE ECONOMICS, Issue 4 2009Joan Costa-Font ABSTRACT,:,Captivity to a mainstream public insurer, is hypothesized to constrain the choice of purchasing private health insurance, by influencing risk attitudes. Namely, risk averse individuals are more likely to stay captive to the National Health System (NHS). To empirically test this hypothesis we use a small scale database from Catalonia to explore the determinants of private health insurance (PHI) purchase under different forms of captivity along with a measure of risk attitudes. Our results confirm that the captivity corrections are significant and can potentially bias the estimates of the demand for PHI. Risk aversion increases the probability of an individual being captive to the NHS. The latter suggests a potential behavioural (or cultural) mechanism to isolate the influence of risk attitudes on the demand for PHI in publicly financed health systems. [source] Reforming China's Rural Health System , By Adam Wagstaff, Magnus Lindelow, Shiyong Wong and Shuo ZhangASIAN-PACIFIC ECONOMIC LITERATURE, Issue 1 2010Jane Carthey No abstract is available for this article. [source] Co-Production and Health System Reform , From Re-Imagining To Re-MakingAUSTRALIAN JOURNAL OF PUBLIC ADMINISTRATION, Issue 1 2009Roger Dunston There is growing interest in the application of citizen participation within all areas of public sector service development, where it is increasingly promoted as a significant strand of post-neoliberal policy concerned with re-imagining citizenship and more participatory forms of citizen/consumer engagement. The application of such a perspective within health services, via co-production, has both beneficial, but also problematic implications for the organisation of such services, for professional practice and education. Given the disappointing results in increasing consumer involvement in health services via ,choice' and ,voice' participation strategies, the question of how the more challenging approach of co-production will fare needs to be addressed. The article discusses the possibilities and challenges of system-wide co-production for health. It identifies the discourse and practice contours of co-production, differentiating co-production from other health consumer-led approaches. Finally, it identifies issues critically related to the successful implementation of co-production where additional theorisation and research are required. [source] IS THERE A ,SECESSION OF THE WEALTHY'?BULLETIN OF ECONOMIC RESEARCH, Issue 3 2008PRIVATE HEALTH INSURANCE UPTAKE AND NATIONAL HEALTH SYSTEM SUPPORT I1; G1 ABSTRACT The purchase of private health insurance (PHI) as a means to partially supplement the National Health System (NHS) coverage is often regarded as a potential signal for a declining support for the NHS. Exploiting the fact that PHI is typically purchased by the most affluent, in this paper we test the so called ,secession of the wealthy' hypothesis whereby the likelihood of expressing ,lack of support for the NHS' increases with having supplementary PHI. Using empirical data from Catalonia, we draw upon an empirical strategy that circumvents an obvious simultaneity problem by estimating both a recursive bivariate probit as well as an IV probit. After controlling for insurance premium, household income and other socio-demographic determinants, we find that the purchase of PHI reduces the propensity of individuals to support the NHS. We also find evidence that PHI is a luxury good and sensitive to fiscal incentives. [source] Drug prescribing by Italian family paediatricians: an exception?ACTA PAEDIATRICA, Issue 5 2010A Clavenna Abstract Aims:, To identify which drugs are considered ,essential' by Italian family paediatricians based on their prescriptions. Methods:, Prescriptions reimbursed by the National Health System, involving 923 177 children < 14 years old, and dispensed during 2005 by the retail pharmacies of 15 local health units (LHUs) in the Lombardy Region, were analysed. The percentage of family paediatricians prescribing each single drug was calculated. A percentage ,75% was considered as a high degree of agreement. Results:, In all, 746 different drugs were prescribed to 486 405 children (52.7%). The median number of drugs prescribed by each paediatrician was 60 (interquartile range 51,71). A total of 22 drugs were prescribed by at least 75% of paediatricians and six were prescribed by all the paediatricians. In all, 95% of the paediatricians prescribed four or more cephalosporins and 92% prescribed four inhaled steroids. Only eight of the 22 most frequent drugs are included in the World Health Organization Essential Medicines for children list. Conclusion:, Despite the huge number of drugs prescribed, only for 22 there was a concordance between family paediatricians. Initiatives to evaluate and promote a more rational use of drugs in Italian children are necessary. [source] Improving Rural Access to Emergency PhysiciansACADEMIC EMERGENCY MEDICINE, Issue 6 2007Daniel A. Handel MD The recent Institute of Medicine report entitled The Future of Emergency Care in the United States Health System acknowledges workforce issues in rural America but does not adequately address the current shortage of emergency medicine residency,trained and board-certified emergency physicians in rural America. Areas worthy of further attention to ameliorate this threat include 1) government and hospital support of emergency medicine resident educational debt load, 2) modification of residency review committee for emergency medicine guidelines to permit modified training programs that are rural focused, and 3) support of pilot projects designed to modify the delivery of rural emergency care under remote supervision by academic medical center,based practitioners. The authors discuss these potential solutions to help guide policy makers seeking to enhance rural emergency care delivery through a stronger emergency medicine workforce. [source] A survey of neonatal resuscitation in Spain: gaps between guidelines and practiceACTA PAEDIATRICA, Issue 5 2009M Iriondo Abstract Objectives: To audit the knowledge and application of internationally recommended newborn resuscitation (NR) guidelines among delivery room (DR) caregivers of Spanish hospitals. Methods: A questionnaire-type survey on NR equipment and practices was performed in hospitals of the Spanish National Health System classified according to level of care provided. Results: 88% of the questionnaires were complimented. Limit of viability was set in 23,24 weeks in 78% of the centres. Availability of board-certified and instructors in NRwas significantly higher in level III versus level I,II centres (94 vs. 70% and 78 vs. 51%, respectively). No differences in equipment or knowledge of guidelines of resuscitation were found between centres. Substantial differences were observed in supplementation and monitorization of oxygen, and positive pressure ventilation during resuscitation and transportation. Conclusion: Equipment availability and knowledge of guidelines of NR does not differ between hospitals independent of their level of care. However, performance during resuscitation and transportation in level III hospitals is in significantly greater acquaintance with internationally recommended NR guidelines. [source] Understanding and changing Health Systems , an instinctive and natural process?JOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 5 2009Carmel M. Martin MBBS MRCGP MSc PhD FAFPHM FRACGP [source] Pluralism, Public Choice, and the State in the Emerging Paradigm in Health SystemsTHE MILBANK QUARTERLY, Issue 1 2002Dov Chernichovsky The conceptualization of medicine as a unique field of endeavor is swiftly changing, and the change involves complex social and technological factors. The concept of "medicine" is dynamic: the range of ailments dealt with by medical care changes, as does the range of therapeutic options. In addition, with the growth in income and education, consumers,especially those in the middle- and upper-income brackets who are self-reliant and stress individualism,expect an increasing diversity of medical care and ins-titutions to supply it (Antonovsky 1987; Schneider, Dennerlein, Kose, et al. 1992; Williams and Calnan 1996). Hence, the character of the product or service offered and demanded is becoming more difficult to determine, especially in socioeconomically advanced communities. In developed nations, the absence of a correlation between a country's expenditures on medical care and the population's health as measured by morbidity and mortality complicates the issue further, since the association between health and the level of investment in medical care is not always as might be expected (OECD 1990). [source] Breast Cancer Incidence in a Cohort of Women with Benign Breast Disease from a Multiethnic, Primary Health Care PopulationTHE BREAST JOURNAL, Issue 2 2007Maria J. Worsham PhD Abstract:, Women with benign breast diseases (BBD), particularly those with lesions classified as proliferative, have previously been reported to be at increased risk for subsequent development of breast cancer (BC). A cohort of 4970 women with biopsy-proven BBD, identified after histopathology review of BBD biopsies, was studied for determination of subsequent development of BC. We report on 4537 eligible women, 28% of whom are African-American, whose BBD mass was evaluable for pathologic assessment of breast tissue. Ascertainment of subsequent progression to BC from BBD was accomplished through examination of the tumor registries of the Henry Ford Health system, the Detroit SEER registry, and the State of Michigan cancer registry. Incidence rates (IR) are reported per 100,000 person years at risk (100 k pyr). Poisson regression models were used to evaluate the association of demographic and lesion characteristics with BC incidence, using person years at the time of BBD diagnosis as the offset variable. The estimated overall BC IR for this cohort is 452 (95% confidence interval [CI] = 394,519) per 100 k pyr. Incidence for women age 50 and older is 80% greater than for younger women (p = 0.007, IRR = 1.8, 95% CI = 1.36,2.36). Neither marital status (p = 0.91, IRR = 0.97, 95% CI = 0.73,1.29) nor race (p = 0.67, IRR = 0.9, 95% CI = 0.54,1.48) is associated with differences in BC IR. Compared with women having nonproliferative lesions, the risk for BC is greater for women with atypical ductal hyperplasia of (IRR = 5.0; 95%CI = 2.26,11.0; p < 0.001) and other proliferative lesions (IR = 1.7, 95% CI = 1.02,2.95; p = 0.04). BC risk for woman with atypical lesions is significantly higher than for women with proliferative lesions without atypia (IRR = 2.58, 95% CI = 1.35,4.90; p = 0.0039). Neither race nor marital status was a factor for BC incidence from BBD in this cohort. Age retained its importance as a predictor of risk. BBD lesion histopathology in the outcome categories of either proliferative without atypia or proliferative with atypia are significant risk factors for BC, even when adjusted for the influence of demographic characteristics. The risks associated with BBD histological classifications were not different across races. [source] Role of medicines in malaria control and eliminationDRUG DEVELOPMENT RESEARCH, Issue 1 2010Marian Warsame Abstract Antimalarial medicines constitute important tools to cure and prevent malaria infections, thereby averting death and disability; their role in reducing the transmission of malaria is becoming increasingly important. Effective medicines that are currently available include artemisinin-based combination therapies (ACTs) for uncomplicated malaria, parenteral and rectal formulations of artemisinin derivatives and quinine injectables for severe malaria, and primaquine as an anti-relapse agent. These medicines are not optimal, however, owing to safety considerations in specific risk groups, complex regimens, and less than optimal formulations. The efficacy of antimalarial medicines including currently used ACTs is threatened by parasite resistance. Resistance to artemisinins has recently been identified at the Cambodia,Thailand border. Intermittent preventive treatment is constrained by the lack of a replacement for sulfadoxine-pyrimethamine. Despite increasing financial support to procure medicines, access to medicines by populations at risk of malaria, particularly in African countries, remains poor. This is largely due to weak health systems that are unable to deliver quality diagnostics and medicines through an efficient supply chain system, close at hand to the sick patient, especially in remote rural areas. Health systems are also challenged by incorrect prescribing practices in the informal and often unregulated private sector (an important provider of medicines for malaria) and the proliferation of counterfeit and substandard medicines. The provision of a more equitable access to life-saving medicines requires no less than a steady drug development pipeline for new medicines tailored to meet the challenging conditions in endemic countries, ideally single dose, highly effective against both disease and relapse-causing parasites and infective forms, extremely safe and with a long shelf life, and made available at affordable prices. Drug Dev Res 71: 4,11, 2010. © 2010 Wiley-Liss, Inc. [source] Health systems in East Asia: what can developing countries learn from Japan and the Asian Tigers?HEALTH ECONOMICS, Issue 5 2007Adam Wagstaff Abstract The health systems of Japan and the Asian Tigers (Hong Kong, Korea, Singapore and Taiwan), and the recent reforms to them, provide many potentially valuable lessons to East Asia's developing countries. All five systems have managed to keep a check on health spending despite their different approaches to financing and delivery. These differences are reflected in the progressivity of health finance, but the precise degree of progressivity of individual sources and the extent to which households are vulnerable to catastrophic health payments depend on the design features of the system , the height of any ceilings on social insurance contributions, the fraction of health spending covered by the benefit package, the extent to which the poor face reduced copayments, whether there are caps on copayments, and so on. On the delivery side, too, Japan and the Tigers offer some interesting lessons. Singapore's experience with corporatizing public hospitals , rapid cost and price inflation, a race for the best technology, and so on , illustrates the difficulties of corporatization. Korea's experience with a narrow benefit package illustrates the danger of providers shifting demand from insured services with regulated prices to uninsured services with unregulated prices. Japan, in its approach to rate setting for insured services, has managed to combine careful cost control with fine-tuning of profit margins on different types of care. Experiences with DRGs in Korea and Taiwan point to cost-savings but also to possible knock-on effects on service volume and total health spending. Korea and Taiwan both offer important lessons for the separation of prescribing and dispensing, including the risks of compensation costs outweighing the cost savings caused by more ,rational' prescribing, and cost-savings never being realized because of other concessions to providers, such as allowing them to have onsite pharmacists. Copyright © 2006 John Wiley & Sons, Ltd. [source] The Effects of Ambulance Diversion: A Comprehensive ReviewACADEMIC EMERGENCY MEDICINE, Issue 11 2006Julius Cuong Pham MD Objectives To review the current literature on the effects of ambulance diversion (AD). Methods The authors performed a systematic review of AD and its effects. PubMed, EMBASE, the Cochrane database, societal meeting abstracts, and references from relevant articles were searched. All articles were screened for relevance to AD. Results The authors examined 600 citations and reviewed the 107 articles relevant to AD. AD is a common occurrence that is increasing in frequency. AD is associated with periods of emergency department (ED) crowding (Mondays, mid-afternoon to early evening, influenza season, and when hospitals are at capacity). Interventions that redesign the AD process or that provide additional hospital or ED resources reduce diversion frequency. AD is associated with increased patient transport times and time to thrombolytics but not with mortality. AD is associated with loss of estimated hospital revenues. Short of anecdotal or case reports, no studies measured the effect of AD on ED crowding, morbidity, patient and provider satisfaction, or EMS resource utilization. Conclusions Despite its common use, there is a relative paucity of studies on the effects of AD. Further research into these effects should be performed so that we may understand the role of AD in the health system. [source] Physicians' Preparedness for Bioterrorism and Other Public Health PrioritiesACADEMIC EMERGENCY MEDICINE, Issue 11 2006G. Caleb Alexander MD Objectives Potential bioterrorism challenges policy makers to balance competing public health priorities. Earlier surveys showed low physician bioterrorism preparedness but did not assess physicians' general public health preparedness, compare the preparedness of emergency and primary care physicians, or assess temporal trends. Methods This was a national, cross-sectional, random-sample survey conducted in 2003. Results Overall, 744 of 1,200 eligible physicians responded (response rate, 62%). Of these, 58% of emergency physician respondents and 48% of primary care physician respondents reported having learned a lot about responding to bioterror since September 11, 2001 (p < 0.01). However, only 43% of emergency physicians and 21% of primary care physicians agreed they are generally "well prepared to play a role in responding to a bioterror attack" (p < 0.001). Beliefs about balancing public health priorities were similar among emergency and primary care respondents. Seventy-eight percent of respondents believed that local health care systems need to be prepared for bioterrorism, and 92% believed that local health care systems need to be prepared for natural epidemics. By contrast, only 23% and 46% of respondents reported that their local health care systems are well prepared for bioterrorism and natural epidemics, respectively. Meanwhile, 77% agreed that "influenza is a greater threat to public health than bioterrorism," and 21% reported that bioterrorism preparedness efforts are diverting resources from more important public health problems. Conclusions In 2003, most emergency and primary care physicians reported that they and their local health care systems were not yet well prepared to respond to a bioterror attack, and many believed that more resources should go toward preparing for natural epidemics. These findings highlight the importance of expanding bioterrorism preparedness efforts to improve the public health system more broadly. [source] OVERCOMING BARRIERS TO PAIN RELIEF IN THE CARIBBEANDEVELOPING WORLD BIOETHICS, Issue 3 2009CHERYL MACPHERSON ABSTRACT This paper examines pain and pain relief in the Caribbean, where pain is widely perceived as an unavoidable part of life, and where unnecessary suffering results from untreated and under treated pain. Barriers to pain relief in the Caribbean include patient and family attitudes, inadequate knowledge among health professionals and unduly restrictive regulations on the medical use of opioids. Similar barriers exist all over the world. This paper urges medical, nursing and public health professionals, and educators to examine attitudes towards pain and pain relief and to work towards making effective pain relief and palliation more accessible. It recommends that i) health professionals and officials be better educated about pain, palliation and opioids, ii) regulatory restrictions be updated in light of clinical and scientific evidence, iii) opioid procurement policies be adjusted to facilitate increased medical use, iv) medical charts and records be modified to routinely elicit and document patients levels of pain, and v) educational campaigns be developed to inform the public that moderate and severe pain can be safely relieved at the end of life and other stages of life. The professional, respectful, and beneficent response to patients in pain is to provide rapid and aggressive pain relief or to urgently consult a pain or palliative specialist. When a health system hinders such efforts the ethical response is to identify, facilitate and advocate for overcoming barriers to improvement. [source] DEFINING STANDARD OF CARE IN THE DEVELOPING WORLD: THE INTERSECTION OF INTERNATIONAL RESEARCH ETHICS AND HEALTH SYSTEMS ANALYSISDEVELOPING WORLD BIOETHICS, Issue 2 2005ADNAN A. HYDER ABSTRACT In recent years there has been intense debate regarding the level of medical care provided to ,standard care' control groups in clinical trials in developing countries, particularly when the research sponsors come from wealthier countries. The debate revolves around the issue of how to define a standard of medical care in a country in which many people are not receiving the best methods of medical care available in other settings. In this paper, we argue that additional dimensions of the standard of care have been hitherto neglected, namely, the structure and efficiency of the national health system. The health system affects locally available medical care in two important ways: first, the system may be structured to provide different levels of care at different sites with referral mechanisms to direct patients to the appropriate level of care. Second, inefficiencies in this system may influence what care is available in a particular locale. As a result of these two factors locally available care cannot be equated with a national ,standard'. A reasonable approach is to define the national standard of care as the level of care that ought to be delivered under conditions of appropriate and efficient referral in a national system. This standard is the minimum level of care that ought to be provided to a control group. There may be additional moral arguments for higher levels of care in some circumstances. This health system analysis may be helpful to researchers and ethics committees in designing and reviewing research involving standard care control groups in developing country research. [source] | |||||||||||||||||||||||||||||||||||||||||||