Is a determination of medical futility ethical?

Medical futility is a timely topic and one fraught with ethical implications. Medical futility is a term used to describe medical interventions that are expected to result in little or no benefit to a patient. This Editorial examines some considerations and applications of medical futility to a specific patient or treatment, the ramifications of the use of the term futility, and its effects on physician-patient communication and the role of the health care administrator. Invoking medical futility is fraught with areas of vulnerability and implications in ethical decision making. Of concern is whether the treatment will cause more harm than good (nonmaleficence), whether it respects patients' goals and desires (autonomy), and whether the interests of patients, society, and the organization are served (justice).     

Is there a contradiction between telemedicine and business?

Is there a contradiction between telemedicine and business? The driving forces in the telemedicine market are: competition within the health-care industry, newly developed cheap information technology (especially the Internet) and 21st-century health-care consumers, with their expectations of free choice and a high level of health-care. The market has four segments (citizens, patients, professionals and employees) and the boundaries between these segments are blurred. The telemedicine market is obviously growing, but it is still unstructured, fractured and disorganized. The telemedicine market needs a meeting place where the status of telemedicine and telecare can be reviewed. This would be a place in which to explore new ways to improve the efficiency of health-care services and a forum in which to draw a roadmap for future developments. One such place is the International Trade Event and Conference for eHealth, Telemedicine and Health ICT, Med-e-Tel. At the 2004 event, there were 32 exhibitors from 23 countries and over 400 industry and medical participants. A survey of participants showed that the event was judged to be a success. There is no conflict between telemedicine and business. On the contrary, telemedicine is a promising area of business development.     

Is there a geography of alternative medical treatment in The Netherlands?

An increasing number of people are using alternative medical care. The literature suggests that there are important between place variations, however. This paper tries to assess the extent of these variations and mechanisms behind them for the utilization of homeopathy, paranormal healing and manual therapy. Are these variations a matter of level of supply, degree of urbanization, GP characteristics or simply a matter of composition of populations? Data are derived from the Dutch National Surgery of General Practice and analyzed using multilevel logistic regression models. Between place variation in utilization of homeopathy is mainly a matter of composition of populations with respect to health locus of control and religion. With respect to paranormal healing, it is exclusively a matter of religion. With respect to manual therapy, place variations are a matter of individual, GP, as well as area characteristics, but a relatively large amount remains unexplained.     

Home uterine monitoring: a case of telemedicine failure?

The aim of the article is to explore and explain some of the controversies around home uterine monitoring, using a socio-technical interaction networks (STIN) approach. A Cochrane systematic review identified 15 included studies. A critique of these studies, using the eight components of the STIN framework, illustrated very clearly the different assumptions made about the purpose of home uterine monitoring, and helped to explain the different outcomes. The final mapping stage suggested that systems architecture choices included that of the role of monitoring support, to complement patient education or to enhance education for provider and patient. A similar choice concerned the type and extent of patient-care-provider contacts to be used. Using the STIN framework provided a useful perspective on the telemedicine aspects of home uterine monitoring, providing value beyond the systematic review conclusions alone.     

Is there a time trend in medical practice variations?

The aim of this study was to review the research evidence for a decreasing time trend in medical practice variation and to contribute to our theoretical understanding of trends in medical practice variations. We searched PubMed for articles reporting on time trends in medical practice variations. Eleven relevant articles were identified. The studies we found tend to show a downward trend in practice variation. Six of the eleven studies show a decrease in practice variation, three studies report more or less stable variation, and only two show increasing variation. The number of studies is, however, small and the aspects of medical practice that were studied in these articles are diverse. A trend in medical practice variation can probably best be explained by institutional changes within and outside health care, which on the one hand directly lead to decreased practice variation and on the other hand make the working environment of physicians more uniform.     

Is consent required for publication of medical errors?

Publication of information about medical errors is critical to error prevention and shared learning among health professionals and institutions. While some countries have error reporting systems in place, journal publications are still essential reference tools for learning about error, and editorial policies about when to publish errors are needed, as these provide important guidance to journal editorial boards. While there is a prima facie moral requirement to obtain consent to publish patient information, publication without patient consent may be justified if certain criteria are met. Justification will involve consideration of a variety of principles, rules and conditions grounded in ethics, law and policy. Except in exceptional circumstances of overriding importance to public health, a patient's personal information should not be published over the patient's refusal. But what constitutes "exceptional circumstances of overriding importance to public health"? We argue that medical error is one such circumstance and present an argument in favour of a specific policy stance on publication of medical errors.     

Is contracting a form of privatization?

Contracting is often seen as a form of privatization, with contracts functioning as the tool that makes privatization possible. But contracting is also viewed by some as a means for the private sector to expand in a covert way its presence within the health sector. This article discusses the wider meaning of the term privatization in the health sector and the ways in which it is achieved. Privatization is seen here not simply as an action that leads to a new situation but also as one that leads to a change in behaviour. It is proposed that privatization may be assessed by looking at the ownership, management, and mission or objectives of the entity being privatized. Discussed also is the use of contracting by the state as a tool for state interventionism that is not based on authoritarian regulation.     

Is travel distance a barrier to veterans' use of VA hospitals for medical surgical care?

Lengthy travel distances may explain why relatively few veterans in the United States use VA hospitals for inpatient medical/surgical care. We used two approaches to distinguish the effect of distance on VA use from other factors such as access to alternatives and veterans' characteristics. The first approach describes how disparities in travel distance to the VA are related to other characteristics of geographic areas. The second approach involved a multivariate analysis of VA use in postal zip code areas (ZCAs). We used several sources of data to estimate the number of veterans who had priority access to the VA so that use rates could be estimated. Access to hospitals was characterized by estimated travel distance to inpatient providers that typically serve each ZCA. The results demonstrate that travel distance to the VA is variable, with veterans in rural areas traveling much farther for VA care than veterans in areas of high population density. However, Medicare recipients also travel farther in areas of low population density. In some areas veterans must travel lengthy distances for VA care because VA hospitals which were built over the past few decades are not located close to areas in which veterans reside in the 1990s. The disparities in travel distance suggest inequitable access to the VA. Use of the VA decreases with increases in travel distance only up to about 15 miles, after which use is relatively insensitive to further increases in distance. The multivariate analyses indicate that those over 65 are less sensitive to distance than younger veterans, even though those over 65 are Medicare eligible and therefore have inexpensive access to alternatives. The results suggest that proximity to a VA hospital is only one of many factors determining VA use. Further research is indicated to develop an appropriate response to the needs of the small but apparently dedicated group of VA users who are traveling very long distances to obtain VA care.     

Is stress straining your medical practice?

Stress in the workplace is not new. But many signs are pointing to the fact that it is a greater threat than ever before. While process improvement strategies, technology, and continued learning have made some things easier, they have also added to the anxieties of business life through information overload, heightened pressure for productivity, and a strong sense of job insecurity.