Excess capacity: markets regulation, and values.
OBJECTIVE: To examine the conceptual bases for the conflicting views of excess capacity in healthcare markets and their application in the context of today's turbulent environment. STUDY SETTING: The policy and research literature of the past three decades. STUDY DESIGN: The theoretical perspectives of alternative economic schools of thought are used to support different policy positions with regard to excess capacity. Changes in these policy positions over time are linked to changes in the economic and political environment of the period. The social values implied by this history are articulated. DATA COLLECTION: Standard library search procedures are used to identify relevant literature. PRINCIPAL FINDINGS: Alternative policy views of excess capacity in healthcare markets rely on differing theoretical foundations. Changes in the context in which policy decisions are made over time affect the dominant theoretical framework and, therefore, the dominant policy view of excess capacity. CONCLUSIONS: In the 1990s, multiple perspectives of optimal capacity still exist. However, our evolving history suggests a set of persistent values that should guide future policy in this area. (+info)
Image processing strategies in picture archiving and communication systems.
An image processing strategy is presented that assures very similar soft-copy presentation on diagnostic workstations of a picture archiving and communication system (PACS) over the lifetime of an image file and simultaneously provides efficient work-flow. The strategy is based on rigid partitioning of image processing into application- and display-device-specific processing. Application-specific processing is optimized for a reference display system. A description of this system is attached to the file header of the application-specifically processed image which is stored in the PACS. Every diagnostic display system automatically reproduces the image quality for which the application-specific processing was optimized by adjusting its properties by display-system-specific processing so that the system becomes effectively equal to the reference display system. (+info)
Referral of patients to an anticoagulant clinic: implications for better management.
The quality of anticoagulant treatment of ambulatory patients is affected by the content of referral letters and administrative processes. To assess these influences a method was developed to audit against the hospital standard the referral of patients to one hospital anticoagulant clinic in a prospective study of all (80) new patients referred to the clinic over eight months. Administrative information was provided by the clinic coordinator, and the referral letters were audited by the researchers. Referral letters were not received by the clinic for 10% (8/80) of patients. Among the 72 referral letters received, indication for anticoagulation and anticipated duration of treatment were specified in most (99%, 71 and 81%, 58 respectively), but only 3% (two) to 46% (33) reported other important clinical information (objective investigations, date of starting anticoagulation, current anticoagulant dose, date and result of latest international normalised ratio, whether it should be the anticoagulant clinic that was eventually to stop anticoagulation, patients' other medical problems and concurrent treatment. Twenty two per cent (16/80) of new attenders were unexpected at the anticoagulant clinic. Most patients' case notes were obtained for the appointment (61%, 47/77 beforehand and 30% 23/77 on the day), but case notes were not obtained for 9% (7/77). The authors conclude that health professionals should better appreciate the administrative and organisational influences that affect team work and quality of care. Compliance with a well documented protocol remained below the acceptable standard. The quality of the referral process may be improved by using a more comprehensive and helpful referral form, which has been drawn up, and by educating referring doctors. Measures to increase the efficiency of the administrative process include telephoning the clinic coordinator directly, direct referrals through a computerised referral system, and telephone reminders by haematology office staff to ward staff to ensure availability of the hospital notes. The effect of these changes will be assessed in a repeat audit. (+info)
The potential of health sector non-governmental organizations: policy options.
Non-governmental organizations (NGOs) have increasingly been promoted as alternative health care providers to the state, furthering the same goals but less hampered by government inefficiencies and resource constraints. However, the reality of NGO health care provision is more complex. Not only is the distinction between government and NGO providers sometimes difficult to determine because of their operational integration, but NGOs may also suffer from resource constraionts and management inefficiencies similar to those of government providers. Some registered NGOs operate as for-profit providers in practice. Policy development must reflect the strengths and weaknesses of NGOs in particular settings and should be built on NGO advantages over government in terms of resource mobilization, efficiency and/or quality. Policy development will always require a strong government presence in co-ordinating and regulating health care provision, and an NGO sector responsive to the policy goals of government. (+info)
Quality: link with effectiveness.
In summary, though the notion of "quality of care" has become fashionable, most of the focus has been on initiatives such as the patient's charter, waiting times, quality of the physical environment, patient centredness in outcomes measurement, etc. Nevertheless, at the heart of quality must be the effectiveness and cost effectiveness of interventions. Without ensuring that health technologies are effective and are delivered appropriately then many of the other dimensions of quality may simply be window dressing. Substantial variations in the rates of procedures, the way in which similar patients are treated, and the degree to which professionals often ignore the best scientific evidence have all been well documented. The NHS needs methods for ensuring that the effectiveness dimension of quality is brought to the fore and becomes a routine part of quality assessment and activity. Clinical autonomy can no longer be an excuse for inappropriate care. The challenge for the future is twofold: to increase the amount of health technology assessment carried out and to develop methods of ensuring that health care converges with this best practice--that is, the promotion of evidence based practice. By introducing evidence based clinical guidelines and associated utilisation review and persuading purchasers to "purchase protocols" rather than just procedures the effectiveness dimension may become more routine, but it will require a radical rethink of the type of data collected and the way in which the purchaser provider split is managed. (+info)
Managing the health care market in developing countries: prospects and problems.
There is increasing interest in the prospects for managed market reforms in developing countries, stimulated by current reforms and policy debates in developed countries, and by perceptions of widespread public sector inefficiency in many countries. This review examines the prospects for such reforms in a developing country context, primarily by drawing on the arguments and evidence emerging from developed countries, with a specific focus on the provision of hospital services. The paper begins with a discussion of the current policy context of these reforms, and their main features. It argues that while current and proposed reforms vary in detail, most have in common the introduction of competition in the provision of health care, with the retention of a public monopoly of financing, and that this structure emerges from the dual goals of addressing current public sector inefficiencies while retaining the known equity and efficiency advantages of public health systems. The paper then explores the theoretical arguments and empirical evidence for and against these reforms, and examines their relevance for developing countries. Managed markets are argued to enhance both efficiency and equity. These arguments are analysed in terms of three distinct claims made by their proponents: that managed markets will promote increased provider competition, and hence, provider efficiency; that contractual relationships are more efficient than direct management; and that the benefits of managed markets will outweigh their costs. The analysis suggests that on all three issues, the theoretical arguments and empirical evidence remain ambiguous, and that this ambiguity is attributable in part to poor understanding of the behaviour of health sector agents within the market, and to the limited experience with these reforms. In the context of developing countries, the paper argues that most of the conditions required for successful implementation of these reforms are absent in all but a few, richer developing countries, and that the costs of these reforms, particularly in equity terms, are likely to pose substantial problems. Extensive managed market reforms are therefore unlikely to succeed, although limited introduction of particular elements of these reforms may be more successful. Developed country experience is useful in defining the conditions under which such limited reforms may succeed. There is an urgent need to evaluate the existing experience of different forms of contracting in developing countries, as well as to interpret emerging evidence from developed country reforms in the light of conditions in developing countries. (+info)
Community asthma clinics: 1993 survey of primary care by the National Asthma Task Force.
OBJECTIVES: To establish a baseline of work done in primary care asthma clinics in the United Kingdom and to assess the degree of clinical delegation to nurses and the appropriateness of their training. DESIGN: Prospective questionnaire survey of asthma care in general practices and a subsidiary survey of all family health services authorities (FHSAs) of the number of asthma clinics in their area. SETTING: All 14,251 general practices in the United Kingdom and 117 FHSAs or health boards (Scotland and Northern Ireland). RESULTS: Questionnaires were returned by 4327 (30.4%) general practices, 54% being completed by practice nurses and 22% by general practitioners; in 24% profession was not stated. In all, 77.2% (3339/4327) of respondents ran an asthma clinic. 60 FHSAs state the number of asthma clinics at the time of the general practice survey (total 3653 clinics); within responding FHSAs 1702 (46.6%) practices running an asthma clinic replied to the general practice survey. Clinics exclusive for patients with asthma mostly occurred in practices with five or more general practitioners (70.2%), compared with single-handed practices (31.7%). The average number of asthma clinics run per practice was five a month; the average duration was 2 hours and 20 minutes. 1131 (48.8%) nurses ran clinics by themselves, 1180 (47.9%) with the doctor, and 39 (1.7%) had no medical input. Comprehensive questioning occurred other than for nasal (872, 26.1%) or oesophageal (335, 10.0%) symptoms and use of aspirin and non-steroidal drugs (1161, 33.4%). Growth in children was measured by only a third of respondents. Of the 1131 nurses who ran clinics alone, 251 (22.2%) did so without formal training entailing assessment. CONCLUSION: Asthma clinics are now common in general practice and much of their work is done by nurses, a significant minority of whom may not have had sufficient training. IMPLICATIONS: As this survey is probably biased toward the more asthma aware practices, greater deficiencies in training and standards may exist in other practices. Further evaluation of the effectiveness of asthma clinics is needed. (+info)
Health services research in the English-speaking Caribbean 1984-93: a quantitative review.
Evaluating the effectiveness and efficiency of health services is important for all countries, especially those with limited resources. This study aimed to evaluate the volume and quality of health services research (HSR) conducted in one developing region, the English-speaking Caribbean. Data were abstracted from all 770 abstracts describing presentations at the annual scientific meetings of the Commonwealth Caribbean Medical Research Council for the decade 1984 to 1993. Of these, 341 abstracts were judged to report health services research and were from the English-speaking Caribbean. Hospital services were evaluated in 240 (70%) reports while primary health services were evaluated in only 90 (26%). Most hospital-based studies evaluated the use and outcome of medical and surgical services through the collection of case series and cohorts of cases, with a median sample size of 104 (interquartile range 38 to 320). Evaluations at primary level were more likely to evaluate need or demand for services, were more likely to report cross sectional surveys or randomized trials and included larger numbers of subjects (median 343, interquartile range 121 to 661). Patient-based measures of health status and measures of resource use were not often reported at either primary or secondary level. Estimation and hypothesis testing were infrequently employed in data analysis. A large proportion of the research presented could be classified as HSR but measures are needed to increase the motivation for research into primary care and to improve skills in HSR study design, conduct and analysis among those presently conducting research. (+info)