An analysis of gainsharing in a health care setting

This study examines the effect a gainsharing plan has had on the productivity of two hospitals. Previously, the hospitals had been using a set of ratios to determine changes in productivity. However, we use a nonparametric productivity measure because it simultaneously considers the relationship between the hospitals' inputs and outputs. Our results show that the gainsharing program had no significant effect on productivity in one hospital and a negative effect on productivity in the other hospital. These results raise questions as to whether gainsharing will help health care providers improve productivity.     

Excess health care service utilization and costs associated with underrecognition of psychiatric comorbidity in a medical/surgical inpatient setting

Psychiatric comorbidity is common among chronically medically ill populations and the presence of psychiatric conditions tends to be associated with increased costs and excess utilization of general medical services. The purpose of this pilot investigation was to determine whether differences in nonpsychiatric inpatient hospitalization frequency, duration, and costs existed between patients receiving outpatient psychiatric treatment and patients without identified psychiatric problems. Length of stay and cost information for patients that had at least 1 inpatient medical/surgical hospitalization during a 6-month period was extracted from the hospital's inpatient billing database (n = 10,865). The medical record numbers of these patients were then cross-referenced against the outpatient psychiatry-billing database for the same 6-month period, thereby identifying all patients that had both a nonpsychiatric inpatient hospitalization and an outpatient psychiatry visit (n = 149). Patients identified as having outpatient psychiatry involvement had significantly more nonpsychiatric hospitalizations on average (mean = 1.60) than nonpsychiatric patients (mean = 1.34) during the study period (t4381 = 2.94, P = .003). There was no difference in the total costs associated with these hospitalizations between the 2 groups. Those that had a psychiatry consult during the nonpsychiatric hospitalization had a significantly higher length of stay and costs than those without. Thus, the criteria used to determine whether or not a psychiatry consultation is triggered, and the timing of the consultation request need further study.     

Influence of work environment on emotional health in a health care setting

BACKGROUND: Radical changes are taking place in health care services and might be expected to cause job dissatisfaction, absenteeism, somatic complaints and mental health problems. Research in this area is limited and focused primarily on nurses. AIM: To understand the impact of the work environment on the emotional health of doctors and nurses in a general hospital setting. METHODS: Cross-sectional study using self-reported questionnaires including the General Health Questionnaire, the Posttraumatic Stress Disorder (PTSD) Checklist for Civilians, the Trauma Experiences and Work Environment Scale. RESULTS: The response rates for the study were 28% (60) for doctors and 54% (431) for nurses. Whilst the prevalences of psychiatric disorder, anxiety, depression and PTSD were higher for doctors compared with nurses, this was not statistically significant. Both groups reported witnessing someone badly injured or killed as their most distressing experience (doctors 46% versus nurses 41%). Using multiple logistic regression, significant predictors of emotional health was task orientation for doctors (OR = 1.96, 95% CI = 1.1-3.6), and PTSD (OR = 17.2, 95% CI = 6.0-49.6), work pressure (OR = 1.2, 95% CI = 1.01-1.4) and innovation (OR = 0.81, 95% CI = 0.70-0.94) for nurses. CONCLUSION: The prevalence of psychiatric disorder among the doctors and nurses was similar to that in Britain. Elements of the work environment did impact on the emotional health of health care workers. Organizational development initiatives should include employee mental health issues in order to create a more positive work environment.     

Creating optimal healing environments in a health care setting

As evidence about the benefits of healing environments accumulates, health care organizations are starting to incorporate features into hospital design that reduce stress and promote healing. This article discusses some of the research supporting healing design and provides examples of how it is being used in new construction and renovations.     

Factors associated with health care utilization by the elderly in a public health care system

OBJECTIVE: The objective was to determine the factors associated with the use of health care services by the elderly residing in the community. METHODS: A cross-sectional study on 787 elderly people over 64 years of age from Albacete City (Castilla-La Mancha, Spain). The study was carried out by personal home interviews during a 9-month period. The dependent variables were: health care utilization, and characteristics. The independent variables were: self-reported health status, self-reported morbidity, medication use, functional status, mental health, lifestyle habits, social support, and sociodemographic status. RESULTS: The health care services were used by 74.5% in the last 3 months of which 59.4% were general practitioner visits, 18.4% were to nursing staff, and 16.5% were specialist visits. Laboratory tests were performed in 39.2% and radiological examinations in 24.9%. Emergency visits accounted for 2.4%, and hospitalization, 2.9%. Users of health care services among the elderly population were objectively more ill, although there was a group of healthy individuals who also visited the physician and a large group of elderly with considerable health problems who never saw their physician. In the multivariate analysis, general practitioner utilization was independently associated with a perceived unmet need for care (OR = 3.15), a negative self-reported health status (OR = 2.51), and a lower educational level (OR = 2.41). CONCLUSIONS: Subjective factors as perceived need for care, a negative self-reported health status and lower educational level are important factors that influence in the utilization of health care services.     

Aversion to health inequalities and priority setting in health care

Traditionally aversion to health inequality is modelled through a concave utility function over health outcomes. Bleichrodt et al. [Bleichrodt, H., Diecidue E., Quiggin J., 2004. Equity weights in the allocation of health care: the rank-dependent QALY model. Journal of Health Economics 23, 157-171] have suggested a "dual" approach based on the introduction of explicit equity weights. The purpose of this paper is to analyze how priorities in health care are determined in the framework of these two models. It turns out that policy implications are highly sensitive to the choice of the model that will represent aversion to health inequality.     

Factors associated with the use of screening mammography in a primary care setting

Despite consensus recommendations the usse of screening mammography remins low. We examined physician and patient related variables associated with requests to undergo screening mammography in a primary care setting, in order to assess current barriers to screening mammography at the level of the physician-patient interaction. A sample of 261 women over the age of 50, whose primary care was provided by resident physician in a large, urban, academic medical center were examined. Data concerning patients and physicians demographic and clinical chracteristics were abstracted. The data were analyzed by Chi-square and stepwise logistic regression. Forty-five percent of the patients were offered screening mammography within the study year and 53% were offered mammography over the preceding two years. Variables significantly associated with a request for screening included a previous history of breast disease (p<.001) and the severity of the patient's overall medical conditoin. Patients with an overall medical condition rated as mild were more likely to be requested to undergo screening than patients rated as moderately or severely ill (p<.01). Patients with higher educational levels were also more likely to be offered screening (P=.06). First year popstgraduate (PGY 1) physicians requested more mammograms than PGY 2 or PGY 3 physicians (P<.05). A multivariable model utilizing logistic regression confirmed the association of the significant variables above with screening requests. Physicians were more likely to request mammography in patients at higher risk for developing breast cancer and less likely to request it in patients who had co-morbid illness. Increasing physician understanding of the importance and benefits of mammography and further investigation of strategies to ensure ophysician compliance with mammography recommendations are necessary to increase utilization.     

Environmental health and safety concerns in the health care setting

Increasing attention to the physical, chemical, and biological aspects of the health care environment is evidenced by the actions of consumer groups, as well as state and federal regulatory bodies, and private accreditation and insurance agencies. This paper reviews the major areas of environmental concern within the health care industry and encourages active participation by environmental health professionals in evaluating environmental risk and impacting positive change.     

医疗卫生机构消毒监测结果简要分析

目的 监测评价医疗卫生单位消毒质量，以督促加强消管管理及感染控制工作，保障医疗质量。方法 按《医院消毒技术规范》要求，对51所医疗卫生单位的空气、物体表面、医护人员手指、未使用和使用中的消毒灭菌剂、无菌医疗用品、消毒灭菌器械进行采样监测。结果 发现存在许多问题，其中以空气消毒效果和消毒剂有效成份含量尤为突出，合格率分别为40．74％和40．50％。结论 部分市管医疗机构消毒质量不达标，存在隐患，应定期对其进行指导监督，责成整改，保障医疗安全。     

Standard setting and protection of human health and safety

Human health and safety are determined by the behavior and performance of the individual, or of a piece of equipment, under the prevailing conditions. Setting health or safety standards, which will define a set of conditions to provide protection, requires consideration of many factors, including the level of protection required and the collection and assessment of factual information. The purpose of the paper is to identify and discuss the elements of the standard-setting process and the major issues likely to be associated with it. Occupational exposure values and other initiatives to provide protection of human health from the potential effects of chemicals in Canada are reviewed in the context of recent initiatives and current pressures for change.     

Educational intervention among farmers in a community health care setting

Background Farmers are at increased risk of developing work-related respiratory diseases including asthma, but little is known about their occupational health and safety (OHS) knowledge and exposure prevention practices. Educational interventions may improve knowledge and practice related to prevention. Aims To determine the feasibility of an educational intervention for farmers in a community health centre setting. Methods This was a pilot study. Farmers were recruited by the community health centre and completed a questionnaire on symptoms, OHS knowledge and exposure prevention practices. The intervention group received education on work-related asthma and exposure control strategies, and was offered spirometry and respirator fit testing. All subjects were asked to repeat the questionnaire 6 months later. Results There were 68 study participants of whom 38 formed the intervention group. At baseline, almost 60% of farmers reported having received OHS training and were familiar with material safety data sheets (MSDSs); fewer (approximately 40%) reported knowledge of OHS legislation and availability of MSDSs. Approximately, two-thirds of subjects reported using respiratory protection. The response rate for repeating the questionnaire was 76% in the intervention group and 77% in the controls. Among the intervention subjects, statistically significant increases were observed in reported safety training, familiarity and availability of MSDSs and knowledge of OHS legislation. Conclusions Gaps in OHS knowledge were observed. The educational intervention on OHS knowledge and exposure prevention practices in the community health centre setting was feasible. Larger, more-controlled studies should be undertaken as this study suggests a positive effect on OHS knowledge and prevention practices.     

A minimal-contact smoking cessation program in a health care setting

A minimal-contact smoking cessation program, designed for use in a health care setting, is described. Smokers receiving medical care as inpatients or outpatients at the Ann Arbor (Mich.) Veterans Administration Hospital receive a brief consultation about their smoking from a health practitioner. (For inpatients, the consultation occurs near the time of the patient's discharge from the hospital.) Toward the end of the consultation, if the patient decides to try to quit smoking, he or she is given a self-help smoking cessation kit in a 3-week-diary format. With the practitioner, the smoker fills out the first series of exercises in the kit, including a smoking awareness test, and signs a stop-smoking contract, which is cosigned by the practitioner. The patient takes the kit home, where the remainder of the kit's instructions and exercises are to be followed. Compliance is encouraged by weekly telephone calls from the health practitioner to check on the patient's progress and by offering the patient a State lottery ticket for each week of the diary completed. Although the materials for this program were created for veterans using the Veterans Administration medical care system, the program can be adapted to a variety of health settings and can employ different types of health care practitioners--physicians, nurses, physician's assistants, and allied health care providers.     

Diagnosis of paediatric HIV infection in a primary health care setting with a clinical algorithm

OBJECTIVE: To determine the validity of an algorithm used by primary care health workers to identify children with symptomatic human immunodeficiency virus (HIV) infection. This HIV algorithm is being implemented in South Africa as part of the Integrated Management of Childhood Illness (IMCI), a strategy that aims to improve childhood morbidity and mortality by improving care at the primary care level. As AIDS is a leading cause of death in children in southern Africa, diagnosis and management of symptomatic HIV infection was added to the existing IMCI algorithm. METHODS: In total, 690 children who attended the outpatients department in a district hospital in South Africa were assessed with the HIV algorithm and by a paediatrician. All children were then tested for HIV viral load. The validity of the algorithm in detecting symptomatic HIV was compared with clinical diagnosis by a paediatrician and the result of an HIV test. Detailed clinical data were used to improve the algorithm. FINDINGS: Overall, 198 (28.7%) enrolled children were infected with HIV. The paediatrician correctly identified 142 (71.7%) children infected with HIV, whereas the IMCI/HIV algorithm identified 111 (56.1%). Odds ratios were calculated to identify predictors of HIV infection and used to develop an improved HIV algorithm that is 67.2% sensitive and 81.5% specific in clinically detecting HIV infection. CONCLUSIONS: Children with symptomatic HIV infection can be identified effectively by primary level health workers through the use of an algorithm. The improved HIV algorithm developed in this study could be used by countries with high prevalences of HIV to enable IMCI practitioners to identify and care for HIV-infected children.     

Burnout dimensions and voluntary and involuntary turnover in a health care setting

This study explores the three dimensions of the Maslach Burnout Inventory (MBI) and investigates their relationship to actual turnover in a hospital. Employees who left had significantly higher burnout on all three dimensions than those who stayed with the organization but only two of these dimensions, emotional exhaustion and personal accomplishment, were significantly related to whether the departure was voluntary or involuntary. Interestingly, the employees who left voluntarily had higher emotional exhaustion scores and lower sense of personal accomplishment than those who were terminated.     

Pragmatics of tracking mental health outcomes in a managed care setting

Accountability, cost effectiveness, and continuous quality improvement are essential features of all managed health care systems. However, application of these principles to mental health treatments has lagged behind other health care services. In this article, administrative, practice, and technical issues are addressed through a joint effort between academically based researchers and administrators from two large managed health care organizations. Principles related to the measurement of outcome, instrument selection, and obstacles to the implementation of an ongoing program to assess mental health treatment outcomes are identified. Finally, principles for successfully changing mental health provider behavior toward outcome assessment and the implications of such for mental health delivery systems are discussed.