The ethical dilemma of population-based medical decision making.
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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)
A population-based approach to diabetes management in a primary care setting: early results and lessons learned.
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OBJECTIVE: To determine the effect of a multifaceted program of support on the ability of primary care teams to deliver population-based diabetes care. DESIGN: Ongoing evaluation of a population-based intervention. SETTING/PARTICIPANTS: Group Health Cooperative of Puget Sound, a staff model HMO in which more than 200 primary care providers treat approximately 15,000 diabetic patients. INTERVENTION: A program of support to improve the ability of primary care teams to deliver population-based diabetes care was implemented. The elements of the program are based on an integrated model of well-validated components of delivery of effective care to chronically ill populations. These elements have been introduced since the beginning of 1995, and some aspects of the program were pilot-tested in a few practice sites before being implemented throughout the organization. The program elements include 1) a continually updated on-line registry of diabetic patients; 2) evidence-based guidelines on retinal screening, foot care, screening for microalbuminuria, and glycemic management; 3) improved support for patient self-management; 4) practice redesign to encourage group visits for diabetic patients in the primary care setting; and 5) decentralized expertise through a diabetes expert care team (a diabetologist and a nurse certified diabetes educator) seeing patients jointly with primary care teams. MAIN OUTCOME MEASURES: Patient and provider satisfaction through existing system-wide measurement processes; process measures, health outcomes, and costs are tracked continuously. RESULTS: Patient and provider satisfaction have improved steadily. Interest in and use of the electronic Diabetes Registry have grown considerably. Rates of retinal eye screening, documented foot examinations, and testing for microalbuminuria and hemoglobin A1c have increased substantially. CONCLUSIONS: Providing support to primary care teams in several key areas has made a population-based approach to diabetes care a practical reality in the setting of a staff model HMO. It may be an important mechanism for improving standards of care for many diabetic patients. (+info)
Prevalence of people reporting sensitivities to chemicals in a population-based survey.
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To describe the prevalence and correlates of reports about sensitivities to chemicals, questions about chemical sensitivities were added to the 1995 California Behavior Risk Factor Survey (BRFS). The survey was administered by telephone to 4,046 subjects. Of all respondents, 253 (6.3%) reported doctor-diagnosed "environmental illness" or "multiple chemical sensitivity" (MCS) and 643 (15.9%) reported being "allergic or unusually sensitive to everyday chemicals." Sensitivity to more than one type of chemical was described by 11.9% of the total sample population. Logistic regression models were constructed. Hispanic ethnicity was associated with physician-diagnosed MCS (adjusted odds ratio (OR) = 1.82, 95% confidence interval (CI) 1.21-2.73). Female gender was associated with individual self-reports of sensitivity (adjusted OR = 1.63, 95% CI 1.23-2.17). Marital status, employment, education, geographic location, and income were not predictive of reported chemical sensitivities or reported doctor diagnosis. Surprising numbers of people believed they were sensitive to chemicals and made sick by common chemical exposures. The homogeneity of responses across race-ethnicity, geography, education, and marital status is compatible with a physiologic response or with widespread societal apprehensions in regard to chemical exposure. (+info)
Evaluating the public health impact of health promotion interventions: the RE-AIM framework.
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Progress in public health and community-based interventions has been hampered by the lack of a comprehensive evaluation framework appropriate to such programs. Multilevel interventions that incorporate policy, environmental, and individual components should be evaluated with measurements suited to their settings, goals, and purpose. In this commentary, the authors propose a model (termed the RE-AIM model) for evaluating public health interventions that assesses 5 dimensions: reach, efficacy, adoption, implementation, and maintenance. These dimensions occur at multiple levels (e.g., individual, clinic or organization, community) and interact to determine the public health or population-based impact of a program or policy. The authors discuss issues in evaluating each of these dimensions and combining them to determine overall public health impact. Failure to adequately evaluate programs on all 5 dimensions can lead to a waste of resources, discontinuities between stages of research, and failure to improve public health to the limits of our capacity. The authors summarize strengths and limitations of the RE-AIM model and recommend areas for future research and application. (+info)
Blood pressure level and incidence of myocardial infarction among patients treated for hypertension.
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OBJECTIVES: This study examined the relationship between achieved blood pressure and risk of myocardial infarction among patients treated for hypertension. METHODS: Blood pressure and other cardiovascular risk factors were assessed among 718 myocardial infarction case patients and 2136 matched controls. RESULTS: Blood pressure level was directly related to risk of myocardial infarction. Patients with treated hypertension who had mild elevations in blood pressure accounted for a larger share of the excess myocardial infarction incidence than those who had higher blood pressure readings. CONCLUSIONS: Achieving normotensive levels in treated hypertensive patients with uncontrolled blood pressure might prevent more than 15% of myocardial infarctions in the treated hypertensive population. (+info)
HRSA's Models That Work Program: implications for improving access to primary health care.
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The main objective of the Models That Work Campaign (MTW) is improving access to health care for vulnerable and underserved populations. A collaboration between the Bureau of Primary Health Care (BPHC) at the Health Resources and Services Administration (HRSA) and 39 cosponsors--among them national associations, state and federal agencies, community-based organizations, foundations, and businesses--this initiative gives recognition and visibility to innovative and effective service delivery models. Models are selected based on a set of criteria that includes delivery of high quality primary care services, community participation, integration of health and social services, quantifiable outcomes, and replicability. Winners of the competition are showcased nationally and hired to provide training to other communities, to document and publish their strategies, and to provide onsite technical assistance on request. (+info)
Teaching community diagnosis: integrating community experience with meeting graduate standards for health educators.
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In 1996, the American Association for Health Education and the Society for Public Health Education developed new Standards for the Preparation of Graduate Level Health Educators. Learning to work effectively with communities is an essential part of graduate level health education. This article provides an overview of the community diagnosis (CD) class, a component of the Master's in Public Health program in the Department of Health Behavior and Health Education, School of Public Health, University of North Carolina. CD is a required two-semester class in which student teams work with preceptors to define a client community, assess its needs and strengths, and establish a foundation of quantitative and qualitative data for future community action. This experience provides a strong foundation for development of graduate level competencies and fosters an appreciation for the complexity of partnerships with communities. (+info)
Applying disease management strategies to Medicare.
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Medicare coverage begins for many when they have already developed one or more chronic diseases, and it often pays for the latest and costliest phases. Population-based disease modeling, patient screening, and monitoring would be appropriate interventions for chronic renal disease. Patients who have not yet advanced to end-stage renal disease would benefit from management of diabetes and hypertension, avoidance of nephrotoxic substances, and better preparation for dialysis. Administrative support could take the form of clinical guidelines, physician-led multidisciplinary teams, integrated delivery systems, provider and patient education, and new information technologies. Medicare reflects the long-term public perspective, and thus should further this new direction by supporting education, reimbursing for prevention efforts and allied health services, encouraging efficiency, and monitoring cost and quality outcomes. (+info)