The ethical dilemma of population-based medical decision making. (41/7635)

Over the past several years, there has been a growing interest in population-based medicine. Some elements in healthcare have used population-based medicine as a technique to decrease healthcare expenditures. However, in their daily practice of medicine, physicians must grapple with the question of whether they incorporate population-based medicine when making decisions for an individual patient. They therefore may encounter an ethical dilemma. Physicians must remember that the physician-patient relationship is of paramount importance and that even well-conducted research may not be applicable to an individual patient.  (+info)

Reengineering the picture archiving and communication system (PACS) process for digital imaging networks PACS. (42/7635)

Prior to June 1997, military picture archiving and communications systems (PACS) were planned, procured, and installed with key decisions on the system, equipment, and even funding sources made through a research and development office called Medical Diagnostic Imaging Systems (MDIS). Beginning in June 1997, the Joint Imaging Technology Project Office (JITPO) initiated a collaborative and consultative process for planning and implementing PACS into military treatment facilities through a new Department of Defense (DoD) contract vehicle called digital imaging networks (DIN)-PACS. The JITPO reengineered this process incorporating multiple organizations and politics. The reengineered PACS process administered through the JITPO transformed the decision process and accountability from a single office to a consultative method that increased end-user knowledge, responsibility, and ownership in PACS. The JITPO continues to provide information and services that assist multiple groups and users in rendering PACS planning and implementation decisions. Local site project managers are involved from the outset and this end-user collaboration has made the sometimes difficult transition to PACS an easier and more acceptable process for all involved. Corporately, this process saved DoD sites millions by having PACS plans developed within the government and proposed to vendors second, and then having vendors respond specifically to those plans. The integrity and efficiency of the process have reduced the opportunity for implementing nonstandard systems while sharing resources and reducing wasted government dollars. This presentation will describe the chronology of changes, encountered obstacles, and lessons learned within the reengineering of the PACS process for DIN-PACS.  (+info)

Technology assessment and requirements analysis: a process to facilitate decision making in picture archiving and communications system implementation. (43/7635)

In a time of decreasing resources, managers need a tool to manage their resources effectively, support clinical requirements, and replace aging equipment in order to ensure adequate clinical care. To do this successfully, one must be able to perform technology assessment and capital equipment asset management. The lack of a commercial system that adequately performed technology needs assessment and addressed the unique needs of the military led to the development of an in-house Technology Assessment and Requirements Analysis (TARA) program. The TARA is a tool that provides an unbiased review of clinical operations and the resulting capital equipment requirements for military hospitals. The TARA report allows for the development of acquisition strategies for new equipment, enhances personnel management, and improves and streamlines clinical operations and processes.  (+info)

Branching out with filmless radiology. (44/7635)

Texas Children's Hospital, a 456 bed pediatric hospital located in the Texas Medical Center, has been constructing a large-scale picture archiving and communications system (PACS), including ultrasound (US), computed tomography (CT), magnetic resonance (MR), and computed radiography (CR). Until recently, filmless radiology operations have been confined to the imaging department, the outpatient treatment center, and the emergency center. As filmless services expand to other clinical services, the PACS staff must engage each service in a dialog to determine the appropriate level of support required. The number and type of image examinations, the use of multiple modalities and comparison examinations, and the relationship between viewing and direct patient care activities have a bearing on the number and type of display stations provided. Some of the information about customer services is contained in documentation already maintained by the imaging department. For example, by a custom report from the radiology information system (RIS), we were able to determine the number and type of examinations ordered by each referring physician for the previous 6 months. By compiling these by clinical service, we were able to determine our biggest customers by examination type and volume. Another custom report was used to determine who was requesting old examinations from the film library. More information about imaging usage was gathered by means of a questionnaire. Some customers view images only where patients are also seen, while some services view images independently from the patient. Some services use their conference rooms for critical image viewing such as treatment planning. Additional information was gained from geographical surveys of where films are currently produced, delivered by the film library, and viewed. In some areas, available space dictates the type and configuration of display station that can be used. Active participation in the decision process by the clinical service is a key element to successful filmless operations.  (+info)

Understanding pedestrians' road crossing decisions: an application of the theory of planned behaviour. (45/7635)

This paper reports a study applying the Theory of Planned Behaviour (TPB) to the prediction of pedestrians' road crossing intentions. Respondents (N = 210) completed questionnaires which included scenarios of three potentially dangerous road crossing behaviours, followed by measures of attitude, subjective norm, perceived behavioural control, self-identity and intention. The results indicated that the social psychological variables under consideration were able to explain between 39 and 52% of the variance in intentions to cross the road in the manner depicted in the scenarios. The perceived behavioural control component of the TPB emerged as the strongest predictor of pedestrians' intentions, suggesting that perceptions of control have an important role to play in road safety behaviour. The results are discussed in relation to the predictive utility of the TPB in this area and possible interventions to encourage safe road crossing behaviour.  (+info)

A new physician's guide to evaluating managed care opportunities. (46/7635)

AUDIENCE: This article is designed for new physicians and administrators who evaluate and negotiate as providers with managed care organizations. GOALS: To provide a review of the major issues impacting on medical practices as they develop contractual relationships with managed care organizations. OBJECTIVES: 1. To review the four major types of health maintenance organizations, providing some general detail about the financial policies of each. 2. To outline how utilization review and quality assurance policies can affect individual physician practice. 3. To discuss risk-sharing arrangements employed by managed care organizations, including their financial and clinical impact, and to outline the issues a new physician should consider when evaluating a contract.  (+info)

Efficacy versus effectiveness of carotid endarterectomy. (47/7635)

CONTEXT: Several well-known clinical trials have demonstrated that the value of carotid endarterectomy depends on preoperative symptoms and the degree of carotid artery stenosis. The benefit of surgery also depends on how the results of these clinical trials (defining the efficacy of carotid endarterectomy) are applied to actual clinical practice (the effectiveness of the procedure), where surgical risks are greater. COUNT: The number of carotid endarterectomies needed to prevent one major stroke or death--that is, the number needed to treat (NNT). CALCULATION: Reciprocal of the difference between the 5-year cumulative incidence of major stroke or death with medical therapy and the 5-year cumulative incidence of major stroke or death with carotid endarterectomy. DATA SOURCES: Efficacy was calculated with data from the North American Symptomatic Carotid Endarterectomy Trials and the Asymptomatic Carotid Atherosclerosis Study. In calculating effectiveness, we accounted for increased surgical mortality rates reported in population-based studies. RESULTS: For symptomatic patients, the NNT predicted by the effectiveness model differed little from that estimated by the efficacy model (10 versus 9 for severe carotid stenosis and 29 versus 23 for moderate carotid stenosis). However, the NNT predicted by the effectiveness model was substantially higher than that predicted by the efficacy model for patients with asymptomatic severe stenosis (63 versus 38). CONCLUSIONS: In symptomatic patients, carotid endarterectomy is both efficacious and effective for severe and (to a lesser extent) moderate carotid stenosis. However, in asymptomatic patients, the benefits observed in published trials may overestimate those likely to be achieved in clinical practice.  (+info)

Incorporating clinical outcomes and economic consequences into drug formulary decisions: a practical approach. (48/7635)

BACKGROUND: In 1994, Regence BlueShield (Regence), a large non-staff model health plan, adopted guidelines governing the review of new and existing drug products. However, certain limitations were apparent: adequate data were not available in a timely fashion; unpublished studies and information on unapproved indications were difficult to obtain; data addressing humanistic and economic outcomes were not routinely supplied by manufacturers; and the time required by Regence staff clinical pharmacists to assemble and summarize published clinical studies for the pharmacy and therapeutics (P&T) committee was excessive. OBJECTIVE: To describe the process used by Regence to collect and review clinical, economic, and other health outcomes data as part of the plan's drug formulary adoption process. PROCESS DESCRIPTION: To address these limitations, Regence revised its process to require pharmaceutical manufacturers to submit a detailed dossier with clinical and economic data from published and unpublished studies, along with a disease-based economic model projecting the potential impact that introducing the product would have on health outcomes and economic consequences occurring across the entire Regence system. After performing independent literature reviews to ensure the accuracy and comprehensiveness of the information obtained, clinical pharmacists at Regence complete a detailed summary of each drug for the P&T committee. CONCLUSION: The new process has addressed the limitations of the previous system and, by improving the timeliness and relevance of available information, it supports Regence's goal of maintaining an evidence-based formulary.  (+info)