Design and trial of a new questionnaire for occupational health surveys in companies.
In this article we present an example of our method for instrument development. This method is called the Development Cycle. It consists of four main stages: (1) defining the requirements for an instrument; (2) research, design and pilot testing; (3) implementation and (4) evaluation. An application of the Development Cycle was realized within a project for the development of a basic questionnaire about work and health, to be used at periodic health surveys. This questionnaire had to identify work and work-related health problems in employees with divergent occupations and working conditions. The design of the instrument and the results of its trial in 517 employees is presented. The evaluation of the test results and the modification of the questionnaire are discussed. From 1995, the questionnaire has been implemented in the Dutch OHS services quite successfully. (+info)
Practice patterns, case mix, Medicare payment policy, and dialysis facility costs.
OBJECTIVE: To evaluate the effects of case mix, practice patterns, features of the payment system, and facility characteristics on the cost of dialysis. DATA SOURCES/STUDY SETTING: The nationally representative sample of dialysis units in the 1991 U.S. Renal Data System's Case Mix Adequacy (CMA) Study. The CMA data were merged with data from Medicare Cost Reports, HCFA facility surveys, and HCFA's end-stage renal disease patient registry. STUDY DESIGN: We estimated a statistical cost function to examine the determinants of costs at the dialysis unit level. PRINCIPAL FINDINGS: The relationship between case mix and costs was generally weak. However, dialysis practices (type of dialysis membrane, membrane reuse policy, and treatment duration) did have a significant effect on costs. Further, facilities whose payment was constrained by HCFA's ceiling on the adjustment for area wage rates incurred higher costs than unconstrained facilities. The costs of hospital-based units were considerably higher than those of freestanding units. Among chain units, only members of one of the largest national chains exhibited significant cost savings relative to independent facilities. CONCLUSIONS: Little evidence showed that adjusting dialysis payment to account for differences in case mix across facilities would be necessary to ensure access to care for high-cost patients or to reimburse facilities equitably for their costs. However, current efforts to increase dose of dialysis may require higher payments. Longer treatments appear to be the most economical method of increasing the dose of dialysis. Switching to more expensive types of dialysis membranes was a more costly means of increasing dose and hence must be justified by benefits beyond those of higher dose. Reusing membranes saved money, but the savings were insufficient to offset the costs associated with using more expensive membranes. Most, but not all, of the higher costs observed in hospital-based units appear to reflect overhead cost allocation rather than a difference in real resources devoted to treatment. The economies experienced by the largest chains may provide an explanation for their recent growth in market share. The heterogeneity of results by chain size implies that characterizing units using a simple chain status indicator variable is inadequate. Cost differences by facility type and the effects of the ongoing growth of large chains are worthy of continued monitoring to inform both payment policy and antitrust enforcement. (+info)
Can restrictions on reimbursement for anti-ulcer drugs decrease Medicaid pharmacy costs without increasing hospitalizations?
OBJECTIVE: To examine the impact of a policy restricting reimbursement for Medicaid anti-ulcer drugs on anti-ulcer drug use and peptic-related hospitalizations. DATA SOURCES/STUDY SETTING: In addition to U.S. Census Bureau data, all of the following from Florida: Medicaid anti-ulcer drug claims data, 1989-1993; Medicaid eligibility data, 1989-1993; and acute care nonfederal hospital discharge abstract data (Medicaid and non-Medicaid), 1989-1993. STUDY DESIGN: In this observational study, a Poisson multiple regression model was used to compare changes, after policy implementation, in Medicaid reimbursement for prescription anti-ulcer drugs as well as hospitalization rates between pre- and post-implementation periods in Medicaid versus non-Medicaid patients hospitalized with peptic ulcer disease. PRINCIPAL FINDINGS: Following policy implementation, the rate of Medicaid reimbursement for anti-ulcer drugs decreased 33 percent (p < .001). No associated increase occurred in the rate of Medicaid peptic-related hospitalizations. CONCLUSIONS: Florida's policy restricting Medicaid reimbursement for anti-ulcer drugs was associated with a substantial reduction in outpatient anti-ulcer drug utilization without any significant increase in the rate of hospitalization for peptic-related conditions. (+info)
Neonatal examination and screening trial (NEST): a randomised, controlled, switchback trial of alternative policies for low risk infants.
OBJECTIVE: To evaluate the effectiveness of one rather than two hospital neonatal examinations in detection of abnormalities. DESIGN: Randomised controlled switchback trial. SETTING: Postnatal wards in a teaching hospital in north east Scotland. PARTICIPANTS: All infants delivered at the hospital between March 1993 and February 1995. INTERVENTION: A policy of one neonatal screening examination compared with a policy of two. MAIN OUTCOME MEASURES: Congenital conditions diagnosed in hospital; results of community health assessments at 8 weeks and 8 months; outpatient referrals; inpatient admissions; use of general practioner services; focused analysis of outcomes for suspected hip and heart abnormalities. RESULTS: 4835 babies were allocated to receive one screening examination (one screen policy) and 4877 to receive two (two screen policy). More congenital conditions were suspected at discharge among babies examined twice (9.9 v 8.3 diagnoses per 100 babies; 95% confidence interval for difference 0.3 to 2.7). There was no overall significant difference between the groups in use of community, outpatient, or inpatient resources or in health care received. Although more babies who were examined twice attended orthopaedic outpatient clinics (340 (7%) v 289 (6%)), particularly for suspected congenital dislocation of the hip (176 (3.6/100 babies) v 137 (2.8/100 babies); difference -0.8; -1.5 to 0.1), there was no significant difference in the number of babies who required active management (12 (0.2%) v 15 (0.3%)). CONCLUSIONS: Despite more suspected abnormalities, there was no evidence of net health gain from a policy of two hospital neonatal examinations. Adoption of a single examination policy would save resources both during the postnatal hospital stay and through fewer outpatient consultations. (+info)
General practitioners' continuing education: a review of policies, strategies and effectiveness, and their implications for the future.
BACKGROUND: The accreditation and provision of continuing education for general practitioners (GPs) is set to change with new proposals from the General Medical Council, the Government, and the Chief Medical Officer. AIM: To review the theories, policies, strategies, and effectiveness in GP continuing education in the past 10 years. METHOD: A systematic review of the literature by computerized and manual searches of relevant journals and books. RESULTS: Educational theory suggests that continuing education (CE) should be work-based and use the learner's experiences. Audit can play an important role in determining performance and needs assessment, but at present is largely a separate activity. Educational and professional support, such as through mentors or co-tutors, has been successfully piloted but awaits larger scale evaluation. Most accredited educational events are still the postgraduate centre lecture, and GP Tutors have a variable role in CE management and provision. Controlled trials of CE strategies suggest effectiveness is enhanced by personal feedback and work prompts. Qualitative studies have demonstrated that education plays only a small part in influencing doctors' behavior. CONCLUSION: Maintaining good clinical practice is on many stakeholders' agendas. A variety of methods may be effective in CE, and larger scale trials or evaluations are needed. (+info)
Evaluating a policy of reduced consultant antenatal clinic visits for low risk multiparous women.
OBJECTIVES: To evaluate a change in antenatal care policy to reduce antenatal clinic visits, whereby low risk multiparous women were managed by the primary care team and seen at booking and at 41 weeks' gestation at the consultant antenatal clinic. DESIGN: Comparative study of low risk multiparous women retrospectively identified through the Oxford obstetric data system and cared for by three consultants who changed their policy (group A) or three consultants who maintained their routine care (group B). SETTING: Oxfordshire Health District. SUBJECTS: 2153 low risk multiparous women (1079 group A, 1074 group B) booked for consultant care at John Radcliffe Maternity Hospital between August 1985 and July 1987. MAIN MEASURES: Comparison of pregnancy outcomes, satisfaction with care, and clinic waiting times, during one year before and after the policy change (year 1, year 2). RESULTS: The proportion of women in group A with only one or two consultant clinic visits increased from 19.9% to 57.9% between years 1 and 2 (p < 0.001). Clinic waiting times did not improve. Of five perinatal deaths in group A, one (from postmaturity) could possibly be attributed to the policy change. The proportion of women reaching 42 weeks' gestation rose from 4.7% to 9.2% (p < 0.01); the proportion fully satisfied with their care rose from 68.4% to 82.1% (p < 0.025). No such changes were seen in group B. CONCLUSIONS: The change in policy was successful in reducing hospital antenatal clinic visits. The exercise identified dilemmas around evaluating changes in antenatal care settings. IMPLICATIONS: Criteria to test policy objectives should be selected carefully and rare events assessed prospectively in order to detect problems early. (+info)
Implementing a policy for pneumococcal prophylaxis in a haematology unit after splenectomy.
People who have had a splenectomy for any reason are 40 times more likely to have an overwhelming infection, especially pneumococcal infection, and 17 times more likely to suffer fatal sepsis. The incidence of such life threatening infections is reduced by prophylactic immunisation with polyvalent pneumococcal vaccine and long term antibiotic prophylaxis or instituting prompt antibiotic treatment in the event of fever. This haematology unit agreed a policy of immunisation and antibiotic prophylaxis in June 1988 for all patients undergoing elective splenectomy. The success of this policy was audited in July 1993 by a retrospective analysis of patients' case notes. Seventy four patients were identified as having had a splenectomy, 54 (73%) before June 1988, of whom only 13 (24%) had received both pneumococcal immunisation and antibiotic prophylaxis before implementation of the agreed policy. At the time of audit, 46/74 (62%) patients were recorded as having received immunisation and 64/74 (86%) as receiving antibiotic prophylaxis or a supply of antibiotics to take in the event of a fever. All but one of the 20 patients who had a splenectomy after June 1988, since implementation of the agreed policy, received immunisation and antibiotic prophylaxis. The authors conclude that establishment of a formal agreed policy for pneumococcal prophylaxis for patients undergoing splenectomy has improved the quality of care. (+info)
Health outcomes and managed care: discussing the hidden issues.
Too often the debate over health outcomes and managed care has glossed over a series of complex social, political, and ethical issues. Exciting advances in outcomes research have raised hopes for logical medical reform. However, science alone will not optimize our patients' health, since value judgements are necessary and integral parts of attempts to improve health outcomes within managed care organizations. Therefore, to form healthcare policy that is both fair and efficient, we must examine the fundamental values and ethical concerns that are imbedded in our efforts to shape care. We must openly discuss the hidden issues including: (1) trade-offs between standardization of care and provider-patient autonomy; (2) effects of financial incentives on physicians' professionalism; (3) opportunity costs inherent in the design of insurance plans; (4) responsibilities of managed care plans for the health of the public; (5) judicious and valid uses of data systems; and (6) the politics of uncertainty. (+info)