Perioperative care: preoperative care

With a subject as vast as preoperative care its is impossible in an article of this length to do more than sketch in the broad outlines of assessment and preparation, using a few examples to illustrate certain aspects. Unfortunately the pressure of work in most hospitals is such that the standard of preoperative care is not as high as it might be. Many authors have stressed its values not only in making anaesthesia safer but especially in reducing the incidence of postoperative morbidity--a field that has received too little attention for too long.     

Cancer care. Palliative care. The last days of care

The government has promised a further 12m pounds over three years for end-of-life care, on top of the 50m pounds a year for palliative care. A framework developed by Macmillan Cancer Relief has identified seven gold standards of care including communication, coordination, control of symptoms, carer support and care in the dying phase. The government has committed to doubling the number of palliative care consultants by 2015.     

Managed care as health care rationing

This article is based on the author's presentations to the New York State Governor's Health Care Advisory Board's Task Force on the President's Health Care Plan, November 22, 1993, and to a hearing of the New York State Attorney General on the experience of consumers with health insurers and health maintenance organizations, September 20, 1993. His comments deal with the effects of the Clinton health care reform proposal and other forms of managed care on those most in need of care. Particularly interesting are his suggestions for protecting the rights of health care consumers.     

When the care giver needs care

Case studies are used to illustrate family dysfunction that can occur when the wife and/or mother who has assumed the role of primary care giver is diagnosed and treated for cancer. These women were treated by the liaison psychiatrist and social workers at a large cancer center. The cases are discussed from a framework of family systems theory. Treatment implications for social workers in health care are also presented.     

Health care, not sick care

Senator Tom Harkin announces his introduction of the HeLP (Healthy Lifestyles and Prevention) Act. This comprehensive legislation provides incentives to stimulate health promotion in workplace, school, and community settings, with specific programs for disabled people, food marketing, Medicare reimbursement for preventive services, and research on obesity, and creation of a National Health Promotion Trust Fund to pay for programs by penalties on tobacco companies that fail to cut smoking rates among children, ending federal subsidies for tobacco advertising, and closing other tax loopholes.     

Managed care and integrated health care

Managed care and integrated care may be viewed as stages in the evolution of the U.S. health care system. The authors discuss the essential characteristics of an integrated delivery system, including patient satisfaction, maintenance of clinical skills, cost-effective practice, and professional reputation.     

Quality of care for primary care patients with depression in managed care

OBJECTIVE: To evaluate the process and quality of care for primary care patients with depression under managed care organizations. METHOD: Surveys of 1204 outpatients with depression at the time of and after a visit to 1 of 181 primary care clinicians from 46 primary care clinics in 7 managed care organizations. Patients had depressive symptoms in the previous 30 days, with or without a 12-month depressive disorder by diagnostic interview. Process indicators were depression counseling, mental health referral, or psychotropic medication management at index visit and the use of appropriate antidepressant medication during the last 6 months. RESULTS: Of patients with depressive disorder and recent symptoms, 29% to 43% reported a depression-specific process of care in the index visit, and 35% to 42% used antidepressant medication in appropriate dosages in the prior 6 months. Patients with depressive disorders rather than symptoms only and those with comorbid anxiety had higher rates of depression-specific processes and quality of care (P < .005). Recurrent depression, suicidal ideation, and alcohol abuse were not uniquely associated with such rates. Patients visiting for old problems or checkups received more depression-specific care than those with new problems or unscheduled visits. The 7 managed care organizations varied by a factor of 2-fold in rates of depression counseling and appropriate anti-depressant use. CONCLUSIONS: Rates of process and quality of care for depression as reported by patients are moderate to low in managed primary care practices. Such rates are higher for patients with more severe forms of depression or with comorbid anxiety, but not for those with severe but "silent" symptoms like suicide ideation. Visit context factors, such as whether the visit is scheduled, affect rates of depression-specific care. Rates of care for depression are highly variable among managed care organizations, emphasizing the need for process monitoring and quality improvement for depression at the organizational level.     

Unmet health care and health care utilization

The objective of this study is to examine the causal effect of health care utilization on unmet health care needs. An IV approach deals with the endogeneity between the use of health care services and unmet health care, using the presence of drug insurance and the number of physicians by health region as instruments. We employ three cycles of the Canadian Community Health Survey confidential master files (2003, 2005, and 2014). We find a robustly negative relationship between health care use and unmet health care needs. One more visit to a medical doctor on average decreases the probability of reporting unmet health care needs by 0.014 points. The effect is negative for the women‐only group whereas it is statistically insignificant for men; similarly, the effect is negative for urban dwellers but insignificant for rural ones. Health care use reduces the likelihood of reporting unmet health care. Policies that encourage the use of health care services, like increasing the coverage of public drug insurance and increasing after hours accessibility of physicians, can help reduce the likelihood of unmet health care.     

Patient-reported care coordination: associations with primary care continuity and specialty care use

PURPOSE Care coordination is increasingly recognized as a necessary element of high-quality, patient-centered care. This study investigated (1) the association between care coordination and continuity of primary care, and (2) differences in this association by level of specialty care use.METHODS We conducted a cross-sectional study of Medicare enrollees with select chronic conditions in an integrated health care delivery system in Washington State. We collected survey information on patient experiences and automated health care utilization data for 1 year preceding survey completion. Coordination was defined by the coordination measure from the short form of the Ambulatory Care Experiences Survey (ACES). Continuity was measured by primary care visit concentration. Patients who had 10 or more specialty care visits were classified as high users. Linear regression was used to estimate the association between coordination and continuity, controlling for potential confounders and clustering within clinicians. We used a continuity-by-specialty interaction term to determine whether the continuity-coordination association was modified by high specialty care use.RESULTS Among low specialty care users, an increase of 1 standard deviation (SD) in continuity was associated with an increase of 2.71 in the ACES coordination scale (P <.001). In high specialty care users, we observed no association between continuity and reported coordination (P= .77).CONCLUSIONS High use of specialty care may strain the ability of primary care clinicians to coordinate care effectively. Future studies should investigate care coordination interventions that allow for appropriate specialty care referrals without diminishing the ability of primary care physicians to manage overall patient care.     

Health care without managed care in Japan

The best gross health indices in the world and universal coverage with no overt signs of rationing characterize the Japanese health care system. The delivery system, which consists primarily of private physicians and private hospitals, is functionally independent, but the financing system is strictly regulated. The author argues that this combination is the key to the system's unique success.     

Orem自理模式在产科新生儿护理中的应用

目的 探讨Orem自理理论模式在产妇护理新生儿的应用效果.方法 选择施行剖宫产手术的初产妇100例,随机分为实验组和对照组各50例.实验组在常规护理基础上采用Orem自护理论模式让产妇实现自我护理新生儿,对照组按整体护理模式进行常规护理新生儿.观察两组产妇母乳喂养、新生儿护理技巧与理论知识掌握情况.结果 实验组产妇在掌握母乳喂养掌握情况、新生儿护理技巧及理论知识方面和产妇及家属对收取优质护理项目费满意度均明显优于对照组,差异有统计学意义(P均＜0.01).结论 将Orem自理理论应用在产科新生儿护理中,可发掘产妇护理新生儿的能力,体现了护士自身价值,提升优质护理的内涵,密切了护患关系,是更为先进、科学、合理的护理模式.