Continuing competency for health professionals: caveat emptor

Continuing competency presents a challenge for professionals in the environmental health field and other public heath disciplines. It is argued that traditional continuing professional education alone is inadequate and other alternatives need to be developed which are complementary. Issues and concerns related to mandatory vs. voluntary continuing professional education are discussed. Communities of interest in the process are described which include practitioners, employers, faculty and consumers, each of whom contribute to a definition of competence. A format for increasing interaction among these communities and a credentialing--continuing competency model is presented. The model addresses the notion that obtaining and maintaining competency is an on-going dynamic process.     

Number needed to treat: caveat emptor

Number needed to treat (NNT)-the inverse of the absolute risk reduction resulting from an intervention-was introduced as a yardstick to describe the harm as well as the benefit of therapeutic maneuvers. Analysis using NNT works well when comparing two or more interventions that have their impact over the same period of time in similar populations or patients. Under other conditions, however, analysis based on NNT can produce results that diverge widely from the impact that the interventions can be expected to have on risk of death. This can happen either for entire populations or for an individual when comparing NNTs for interventions which have their effects on different subsets of the population or when comparing interventions which have their effects over different periods of time. We demonstrate how this can occur by comparing the NNTs and effect of intervention on deaths in a population for automatic implantable cardioverter defibrillators (AICDs), heart transplantation, and cholesterol lowering through nutritional intervention with plant stanol ester.     

Equity and equality in health and health care

This paper explores four definitions of equity in health care: equality of utilization, distribution according to need, equality of access, and equality of health. We argue that the definitions of 'need' in the literature are inadequate and propose a new definition. We also argue that, irrespective of how need and access are defined, the four definitions of equity are, in general, mutually incompatible. In contrast to previous authors, we suggest that equality of health should be the dominant principle and that equity in health care should therefore entail distributing care in such a way as to get as close as is feasible to an equal distribution of health.     

Regional variation in health care utilization and mortality

Geographic variation in health care utilization has raised concerns of possible inefficiencies in health care supply, as differences are often not reflected in health outcomes. Using comprehensive Norwegian microdata, we exploit cross-region migration to analyze regional variation in health care utilization. Our results indicate that place factors account for half of the difference in utilization between high and low utilization regions, while the rest reflects patient demand. We further document heterogeneous impacts of place across socioeconomic groups. Place factors account for 75% of the regional utilization difference for high school dropouts, and 40% for high school graduates; for patients with a college degree, the impact of place is negligible. We find no statistically significant association between the estimated place effects and overall mortality. However, we document a negative association between place effects and utilization-intensive causes of death such as cancer, suggesting high-supply regions may achieve modestly improved health outcomes.     

Informal care and health care use of older adults

Informal care by adult children is a common form of long-term care for older adults and can reduce medical expenditures if it substitutes for formal care. We address how informal care by all children affects formal care, which is critically important given demographic trends and the many policies proposed to promote informal care. We examine the 1998 Health and Retirement Survey (HRS) and 1995 Asset and Health Dynamics Among the Oldest-Old Panel Survey (AHEAD) using two-part utilization models. Instrumental variables (IV) estimation controls for the simultaneity of informal and formal care. Informal care reduces home health care use and delays nursing home entry.     

日本预防保健体系对我国构建家庭保健体系的启示

日本的医疗卫生保健体系从广义上讲以预防保健、医疗和照护为三大支柱,并针对儿童、残疾人、老年人等弱势群体通过社会福利政策给予支持,从而打造了全方位的预防保健、医疗、照护、福利网络。随着医疗费用在国民收入中所占比例的不断增加和人口老龄化的不断加剧,日本逐步深化预防保健的重要性,积极促进以治疗为重点的医疗体制向重视疾病预防、健康促进的预防保健医疗体制转变。同时,加强保健、医疗、照护、福利在社区层面的联合。本文重点分析日本预防保健体系的构成及特点,总结其经验,以期为中国强化预防保健意识,促进人口计生系统转型,构建全面深入的家庭预防保健体系提供借鉴和参考。     

Health insurance and imperfect competition in the health care market

We show that when health care providers have market power and engage in Cournot competition, a competitive upstream health insurance market results in over-insurance and over-priced health care. Even though consumers and firms anticipate the price interactions between these two markets - the price set in one market affects the demand expressed in the other - Pareto improvements are possible. The results suggest a beneficial role for Government intervention, either in the insurance or the health care market.     

Changing relations between hospitals and primary health care: new challenges for hospital management

Hospitals in the Netherlands are now operating in a rapidly changing environment. Most changes directly result from government's policy to achieve effective cost containment in health care. Some of them basically affect the existence and functioning of hospitals. These changing environmental conditions inspire hospitals to undertake innovative activities to protect or even strengthen their position. This will be illustrated below by a case in which a small acute hospital attempted to establish a close relationship with primary health care in order to protect its position. Our focus will be upon this innovative initiative and upon some management problems that must then be resolved.     

Financing of health care services in Hungary

In this paper we give a practical overview of the changes in the financing of health care in Hungary. We describe the financing system of general practitioners, home care (nursing), out-patient care and the acute and chronic care of hospitals. We show how the financial system has changed after the political changes of 1990. The global budget approach of the 1980s was replaced by performance-related financing methods including the ICPM (International Classification of Procedures in Medicine) code system of the WHO (World Health Organization) in out-patient care and the introduction of HBCS (Homogén Betegségcsoportok, Homogeneous Disease Groups) in in-patient care. We underline that the efforts made towards reforming health care financing resulted in an activity-related financing system.     

谈卫生事业的发展

该文阐述了新时期卫生事业的发展不能只停留在生产要素量的增长上，而着重要看生产能力质的提高，更要把“服务人群健康水平的提高”作为卫生事业发展的试金石和最终归结点。在确立发展的目标定位时应以卫生事业的服务主体为参照系，而在选择发展的载体时，应从“东一榔头西一锤”、“拆东墙补西墙”、“鹤立鸡群”、“拚设备”等发展的误区里走出来，并从宏观和微观两个层面论述了该怎样发展。     

常用卫生领域绩效评价框架的发展和比较研究

目的:为我国卫生领域绩效评价提供借鉴。方法:阐述常用卫生领域绩效评价框架的发展,从评价对象、主要目标、评价维度、评价指标、应用情况等方面进行比较分析,并讨论其对我国的启示。结果与结论:在进行绩效评价时,需借鉴国外绩效评价理论,辩证地看待评价框架的优缺点,根据评价对象和实际情况选取合适的评价框架。     

Disparities in health care utilization among urban homeless in South Korea: a cross-sectional study

Objectives

We examined health care disparities in Korean urban homeless people and individual characteristics associated with the utilization of health care.

Methods

We selected a sample of 203 homeless individuals at streets, shelters, and drop-in centers in Seoul and Daejeon by a quota sampling method. We surveyed demographic information, information related to using health care, and health status with a questionnaire. Logistic regression analysis was adopted to identify factors associated with using health care and to reveal health care disparities within the Korean urban homeless population.

Results

Among 203 respondents, 89 reported that they had visited health care providers at least once in the past 6 months. Twenty persons (22.5%) in the group that used health care (n = 89) reported feeling discriminated against. After adjustment for age, sex, marital status, educational level, monthly income, perceived health status, Beck Depression Inventory score, homeless period, and other covariates, three factors were significantly associated with medical utilization: female sex (adjusted odds ratio [aOR, 15.95; 95% CI, 3.97 to 64.04], having three or more diseases (aOR, 24.58; 95% CI, 4.23 to 142.78), and non-street residency (aOR, 11.39; 95% CI, 3.58 to 36.24).

Conclusions

Health care disparities in Seoul and Daejeon homeless exist in terms of the main place to stay, physical illnesses, and gender. Under the current homeless support system in South Korea, street homeless have poorer accessibility to health care versus non-street homeless. To provide equitable medical aid for homeless people, strategies to overcome barriers against health care for the street homeless are needed.     

医保对象对职工医疗保险制度反应性的分析

该文对享受上海市城镇职工基本医疗保险的市民进行随机抽样调查,就其对医保政策的评价和就医行为反应性改变,分析医保改革的有效性和震荡度.提出加强医保法制建设,强化费用分担意识,完善医保政策,进一步体现福利性、公益性、公平性.     

Government health insurance and privatization: an examination of the concept and of equity.

After almost a century of the evolution of welfare capitalism in the liberal-democratic countries, and the spread of government intervention in the financing and provision of health services, the debate is now whether or not government can, or should, be as all-encompassing as it has clearly become. What is emerging with greater force is a pattern of private insurance and private provision, though its future is not easy to predict. What is clear, however, is that a modified version of a politically acceptable concept of equity will have to be formulated.     

围绝经期妇女保健状况与卫生需求调查

目的:了解围绝经期妇女的保健状况与卫生服务需求。方法:采用随机抽样方法,对武汉市硚口和江岸七个社区40～60岁的1035名围绝经期妇女保健情况进行面对面问卷调查。结果:1035名围绝经期妇女中只有21.16%定期到医院体检,曾经获得过一种以上保健服务的妇女有482人,占46.57%,而没有享受任何保健服务的有53.43%。希望获得一种以上保健服务的有806人,占77.87%。结论:应加大投入,重视围绝经期妇女的保健工作,强化她们的自我保健意识及满足她们的保健需求。服务个性化、人性化,提倡使用医疗保健卡。     

经济学评价在我国卫生保健中的应用

该文主要介绍了经济学评价在我国卫生保健领域中的应用,通过疾病预防、诊断和治疗的经济学评价实例,说明在卫生保健中引入经济学的理论和方法,有助于提高卫生资源的配置和利用效率,为实现卫生保健的公平、质量和效率服务。     

Pay for performance for antibiotic timing in pneumonia: caveat emptor

BACKGROUND: Health care practitioners and hospital administrators have focused on a performance measure regarding antibiotic timing for patients with community-acquired pneumonia in anticipation of a pay-for-performance program through the Centers for Medicare & Medicaid Services (CMS) and private payers. ANTIBIOTIC TIMING AS A PERFORMANCE MEASURE: Early antibiotic administration is associated with improved outcomes, even after adjusting for severity. Yet although some patients may benefit through the early administration of antibiotics, there is a risk to other patients who are treated concurrently. Some patients' care may be delayed because they may not receive the same priority as patients with suspected pneumonia. Other patients may receive inappropriate antibiotics for suspected pneumonia to shorten the time to administration. POTENTIAL IMPACT OF PAY FOR PERFORMANCE: Attempts to address the performance measure are probably dependent on how well the emergency department functions and the level of crowding. Patients with a suspected pneumonia may be empirically covered with antibiotics before radiographic diagnosis, which should increase the rate of antibiotic administration for antibiotic-nonresponsive conditions and contribute to antibiotic resistance. The answer is to find measures of system throughput and/or work flow that are associated with improved patient care outcomes.