Establishing the validity and reliability of clinical practice guidelines used to identify families requiring increased health visitor support

One of health visitors' main roles is that of case finding and actively searching for health needs. This paper describes part of the findings of a study evaluating the clinical practice guidelines issued to health visitors to assist them in identifying families requiring increased health visitor support. A postal questionnaire was distributed to all Community Trust Chief Nurses in England (179), employing health visiting staff. The aim of the questionnaire was to assess the extent to which clinical guidelines are used throughout the country to identify families requiring extra health visiting support and to examine their validity and reliability. The survey results confirm the widespread existence of clinical guidelines in England to assist health visitors in identifying vulnerable families requiring extra support. The study provides evidence that the guidelines are largely subjective and invalid in nature. Questions are raised about the relationship between clinical guidelines and professional judgements.     

Current health and preferences for life-prolonging treatments: an application of prospect theory to end-of-life decision making

As a substantial body of research attests, the acceptability of life-prolonging treatment (e.g., tube feeding) tends to be greater among people in worse health than among healthier ones. Because a decision for or against a life-prolonging treatment represents a choice between two prospects-life (usually in poor health) and death-we propose a decision model, Prospect Theory, as a theoretical account of this phenomenon. Prospect Theory postulates that pairs of distant prospects are less distinguishable than pairs of closer ones. Thus, to healthy individuals, the prospects of death and life in poor health would both be remote, and therefore, the distinction between them, small. To less healthy individuals, however, the difference between the same pairs of prospects would appear greater, and therefore, life-prolonging treatment may be more acceptable. In a cross-sectional study of 304 community-dwelling people, aged 60 years and over in the Philadelphia area, USA, preferences for 4 life-prolonging treatments in 9 health scenarios were examined in relation to participants' current health, operationalized as number of deficits in physical functioning. As predicted, less healthy people expressed stronger preferences for all life-prolonging treatments compared with healthier ones, with differences greatest in the worse-health scenarios. Preferences also varied by health scenario, with any treatment preferred in the better health scenarios. Treatment preferences did not differ by type of treatment, depressed mood or any demographic characteristic except race, with African-Americans expressing stronger treatment preferences. Implications for advance care planning are discussed.     

Diagnosis related group prospective payment: implications for health care and medical technology

This paper reviews the major features of the new DRG prospective payment system which was introduced for the payment of hospitals under the Medicare program October 1, 1983 in the United States. It explores its general implications for the health sector, and then examines its specific implications for the development, diffusion, and utilization of medical technology. It concludes with some of the research questions that require investigation to provide an informed basis for modification to the payment system that will ensure that quality health care will be provided at an affordable cost.     

Dollars and sense: the economics of personal health decision-making

The economic consequences of personal health care decision-making have received relatively little attention in the United States. The majority of the American public is shielded from an awareness of the cost impact of health services by first dollar health insurance coverage and modest out-of-pocket personal payments. As the various current structural changes in the reimbursement system for health care begin to manifest themselves in terms of mandating individual responsibility for paying a significant portion of health care, Americans will require and demand a deeper understanding of how much their health is costing them. In addition, as individuals realize that up to 50% of disability and death can be attributed to negative lifestyle health behaviors, the interrelationship of personal economic status and health status will create a new consciousness of the value of preventive health practices and health education. This article provides an in-depth analysis of the social forces in America compelling individual health decision-making in economic terms, barriers to informed health decision-making, a suggested matrix for making quality-vested health decisions (with case examples) and a discussion of available resources for assisting in the decision-making process.