Measuring health care effectiveness. Research and policy implications

The implications of effectiveness research are far-reaching. Thus, the specification of a broad research agenda and the soundness of the underlying research methodologies and data bases are critical. This article discusses the quality of administrative data and the infrastructure supporting an ongoing effectiveness research effort.     

The current state of health care in the former Soviet Union: implications for health care policy and reform.

OBJECTIVES. Given the many profound health care problems facing Russia and the other former Soviet republics, there are a number of fundamental policy questions that deserve close attention as part of the reform process. METHODS. Summary data regarding Soviet health care issues were drawn from government agency reports, scholarly books and journals, recent press reports, and the authors' personal research. RESULTS. Smoking, alcohol, accidents, poor sanitation, inadequate nutrition, and extensive environmental pollution contribute to illness and premature mortality in Russia and the other newly independent states. Hospitals and clinics are poorly maintained and equipped; most physicians are poorly trained and inadequately paid; and there is essentially no system of quality management. While efforts at reform, which emphasize shifting to a system of "insurance medicine," have been largely unsuccessful, they have raised several important policy issues that warrant extensive research and discussion. CONCLUSIONS. Without considering the implications and consequences of alternative policy directions, Russia and the other states face the very real possibility of developing health care systems that improve the overall level of care but also incorporate limited access and escalating costs. Russian health care reform leaders can learn from the health care successes in the West and avoid repeating our mistakes.     

Surveillance for equity in primary health care: policy implications from international experience.

Experience around the world shows that health agencies can promote community-based surveillance for equity to focus low-cost interventions on priority needs. Social inequities which have seemed intractable can be resolved if care responds directly to demonstrated need. The concept of promoting equity as a basic principle of primary health care has an interesting psychological twist. The ethical imperative of equity can strengthen services when linked with the practical management tool of surveillance. Moral conviction in applying this social justice norm can facilitate action which is made efficient by the realism of statistically based methods of surveillance. If international agencies condition their aid on surveillance for equity their assistance will more likely go to those in greatest need. This is a more efficient and effective way of tracking their money than the previous tendency to set up vertical programmes which generally have poor sustainability. Surveillance helps mobilize political will and community participation by providing practical data for local, district and national decision-makers. The many field demonstrations of successful surveillance for equity tend to have been brushed off by development experts who say they are difficult to replicate nationally. The Model County Project in China shows how a systematic extension process can test procedures in experimental areas and adapt them for general implementation. Surveillance can help bureaucracies maintain capacity for flexible and prompt response as decentralization promotes decision-making by local units which are held responsible for meeting equity targets. Surveillance for equity provides a mechanism to ensure such accountability.     

At-risk drinking in an HMO primary care sample: prevalence and health policy implications.

OBJECTIVES: This study was designed to determine the prevalence of at-risk drinking using varying alcohol use criteria. METHODS: A period prevalence survey was conducted in 22 primary care practices (n = 19372 adults). RESULTS: The frequency of at-risk alcohol use varied from 7.5% (World Health Organization criteria) to 19.7% (National Institute on Alcohol Abuse and Alcoholism criteria). A stepwise logistic model using National Institute on Alcohol Abuse and Alcoholism criteria found male gender, current tobacco use, never married status, retirement, and unemployment to be significant predictors of at-risk alcohol use. CONCLUSIONS: Public health policy needs to move to a primary care paradigm focusing on identification and treatment of at-risk drinkers.     

Assessment of the FDA backgrounder on platinum in silicone breast implants: implications for public health policy.

A recent report by the U.S. Food and Drug Administration reviewed the literature on the subject of platinum in silicone gel-filled breast implants. In this study the author evaluates the FDA report for scientific accuracy and impartiality, and provides relevant discussions on financial conflicts of interest, an Institute of Medicine report, and public health policy. The study suggests that the FDA used discredited scientific practices in compiling its report. Reports by regulatory agencies should be scientifically accurate, with no partiality to industry. The current policy of one-way information flow from the FDA directly to those being informed needs to be revised. Greater importance should be placed on studies in which authors have no financial conflicts of interest.     

Insurance coverage and access: implications for health policy.

Data are presented from a recent survey of the United States population comparing the characteristics and levels of access to medical care of persons under 65 years who have group or individual private health insurance, public health insurance, or no third-party coverage. The uninsured group appeared to fall between the privately insured and publicly insured groups on measures of social and economic status. Persons with publicly subsidized forms of insurance coverage utilized services at the highest rates, and uninsured persons used them at the lowest rates. Neither of these groups was as satisfied with the convenience or the quality of the care it obtained as the privately insured group. Implications of these findings for national health insurance and other health policy initiatives are discussed.     

The impact of corporate practices on health: implications for health policy

Although corporate practices play a substantial role in shaping health and health behavior, public health researchers have rarely systematically studied these practices as a social determinant of health. We consider case studies of three products - trans fat, a food additive and a preservative; Vioxx, a pain killer; and sports utility vehicles - to illustrate the role of corporate policies and practices in the production of health and disease and the implications for health policy. In recent years, public health advocates, researchers, and lawyers have used strategies to reduce the adverse health impact of corporate practices. Systematic analysis of these experiences yields insights that can guide the development of health policies that increase opportunities for primary prevention by discouraging harmful corporate practices.     

Comprehensive primary health care in South America: contexts, achievements and policy implications

This article summarizes an extensive review of South American experiences with primary health care since the Declaration of Alma-Ata. It aims to address the following specific questions: What are the enabling and constraining historical and structural conditions for primary health care policies and practices? How has health care reform supported or undermined primary health care? What evidence exists on the effectiveness of primary health care? What strategies are common to best practices? What evidence exists on the roles of citizen participation and intersectoral action? And finally, what are the policy lessons to be learned from these experiences? Narrative synthesis was used to identify and examine patterns in the data consistent with these questions. Conditions that were found to promote successful implementation of primary health care are outlined, together with features of effective primary health care systems that help create more equitable health services and health outcomes.     

PSRO: issues in health care policy

Enactment of the law regarding Professional Standards Review Organizations (PSROs) represents a major shift in health care policy in the United States. PSRO is an experiment in developing a national quality assurance system. It raises issues of quality versus cost control, professional versus public accountability, and confidentiality. These issues must be examined critically by social workers.     

Social surveys and health policy implications for national health insurance.

The authors explore the utility of applying social survey data (a) to evaluate the impact of existing health programs and (b) to rank-order priorities concerning future health care policies. Based on national survey data from 1963, 1970, and 1976, they concluded that although Medicare and Medicaid have enabled more people to see a physician than ever before, a large proportion of the population still registers dissatisfaction with the health care they received--particularly with respect to their out-of-pocket costs for obtaining it. However, national health insurance options favored by the majority of the population--particularly those who can best afford the cost of care--suggest preferences for programs that incorporate some mix of existing modes of financing rather than those that provide for substantial restructuring of the current system.     

Assessment of diabetic patient management at primary health care level]

OBJECTIVE: The characterization of diabetic patients seen at a primary health care clinic. METHODS: The case notes of 3,024 families were searched by means of a cross-sectional study for patients 30 to 75 years of age with a diagnosis of diabetes mellitus who had had a medical consultation during the previous five years. These patients were interviewed at their homes and were asked to come to the health center for physical examination and a plasma glucose test using glucosylated hemoglobin (GH). RESULTS: The prevalence of diabetes was 4%. The typical diabetic patient was a white women, > or = 50 years of age, from a family with a monthly income < or = 3 minimum wages. Compliance with GH was observed in 70% of the patients. Diet therapy was followed by less than one third of the patients and only one fifth were engaged in regular exercise. Nearly 70% were undergoing drug therapy (oral hypoglicemic agents or insulin); of these, only 15% used insulin. Most of the patients (66%) who agreed to have the GH test showed normal or fair glucose blood levels. CONCLUSIONS: Great efforts should be made by health teams to enhance diabetic patient education in order to promote compliance with recommendations regarding diet and exercise.     

Reforming the health care system: implications for health care marketers

Health care reform has become the dominant domestic policy issue in the United States. President Clinton, and the Democratic leaders in the House and Senate have all proposed legislation to reform the system. Regardless of the plan which is ultimately enacted, health care delivery will be radically changed. Health care marketers, given their perspective, have a unique opportunity to ensure their own institutions' success. Organizational, managerial, and marketing strategies can be employed to deal with the changes which will occur. Marketers can utilize personal strategies to remain proactive and successful during an era of health care reform. As outlined in this article, responding to the health care reform changes requires strategic urgency and action. However, the strategies proposed are practical regardless of the version of health care reform legislation which is ultimately enacted.     

Assessment of family physicians' performance using patient charts: interrater reliability and concordance with chart-stimulated recall interview

Peer-assessment processes with chart review have been used for many years to assess the clinical performance of physicians. The Quebec medical licensing authority has been required by provincial law to assess the practicing Quebec physicians on a nonvoluntary basis. During the period from January 2001 to November 2004, 25 family physicians in active practice were randomly selected from a pool of about 300. For each physician, 25 to 40 patients' medical charts were randomly selected to evaluate the interrater reliability of peer-review assessment of medical charts and to compare ratings based on chart review with a chart-stimulated recall interview to those based on chart review alone. The concordance between chart review alone and that of chart review with chart-stimulated recall interview was 75% for chart keeping, 69% for clinical investigation, 81% for diagnostic accuracy, and 74% for treatment plan. Ratings based on chart review alone achieve moderate levels of reliability (Kappa = 0.44 to 0.56). It appears that some important information about quality of care is missed when only chart review is used.