Nutrition support in the United States, what is the current practice?

Clinical nutrition in the United States encompasses a vast continuum of nutrition: from the process of identification of malnutition to the management and prevention of obesity. This presentation with focus on the current pratice of nutrition support in the United States. Nutrition support is the provision of specially formulated and/or delivered parenteral or enteral nutrients to maintain or restore optimal nutrition status.     

Nutrition support in the United States, what is the current practice？

Clinical nutrition in the United States encompasses a vast continuum of nutrition:from the process of identification of malnutition to the management and prevention of obesity. This presentation with focus on the current pratice of nutrition support in the United States. Nutrition support is the provision of specially formulated and/or delivered parenteral or enteral nutrients to maintain or restore optimal nutrition status.     

Nutrition care in general practice - are we waiting for patients to ask?

General practitioner encounters for chronic disease management increased considerably between 1998 and 2008. In particular, patients presenting for the management of hypertension increased from 8.3 to 9.9 per 100 encounters; type 2 diabetes mellitus from 2.6 to 3.7 per 100 encounters; and lipid disorders from 2.5 to 3.7 per 100 encounters. In 2010, chronic disease management was estimated to comprise over one-third of the average GP's consultation workload.     

Psychosocial care for cancer patients in primary care? Recognition of opportunities for cancer care

The paper outlines psychosocial problems experienced by cancer patients and the current barriers to service delivery. New models of psychosocial service provision are put forward, emphasizing information, communication and technology aids in an attempt to improve co-ordination of care. The management of cancer patients has evolved greatly over the past decades, and patients are well placed to benefit from the experiences of primary care professionals in the delivery of chronic illness disease management strategies.     

Screening for alcoholism in the primary care setting: are we talking to the right people?

BACKGROUND: This study assessed which demographic groups were most likely to consume alcohol excessively, and which groups had received inquiries and discussion about alcohol use from their physicians compared with discussions about other health risks. STUDY DESIGN: This was a cross-sectional study using data from the Centers for Disease Control Behavioral Risk Factors Surveillance System 1997 data set that represents a stratified random sample in the United States. POPULATION: We selected 23,349 adults who reported a routine physical examination within the last 3 years. OUTCOMES MEASURED: The main variables involved responses to questions about alcohol intake and whether the respondent's physician had initiated discussions about drinking. RESULTS: Physicians spoke to patients about alcohol use much less frequently than about other health-related behaviors. Discussions were roughly targeted to groups with the largest intake. However, physicians were least likely to speak with white patients, women, and widows who drank significantly. CONCLUSIONS: Regularly asking patients about alcohol use could substantially reduce the under-recognition of alcoholism. Since brief counseling is effective, negative consequences of excessive alcohol intake may be avoided.     

Exploring variations in health‐care expenditures—What is the role of practice styles?

Variations in medical resource usage, both across and within geographical regions, have been widely documented. In this paper, we explore physician practice styles as a possible determinant of these variations. In particular, we exploit patient mobility between physicians to identify practice styles among general practitioners (GPs) in Austria. We use a large administrative data set containing detailed information on a battery of different health‐care services and implement a model with additive patient and GP fixed effects that allows flexibly for systematic differences in patients' health states. We find that, although GPs explain only a small part of the overall variation in medical expenses, heterogeneities in spending patterns among GPs are substantial. Conditional on patient characteristics, we document a difference of € 751.47 per patient per year in total medical expenses (which amounts to roughly 45% of the sample mean) between high‐ and low‐spending GPs.     

Assessing the potential for improvement of primary care in 34?countries: a cross-sectional survey

Objective

To investigate patients’ perceptions of improvement potential in primary care in 34 countries.

Methods

We did a cross-sectional survey of 69 201 patients who had just visited general practitioners at primary-care facilities. Patients rated five features of person-focused primary care – accessibility/availability, continuity, comprehensiveness, patient involvement and doctor–patient communication. One tenth of the patients ranked the importance of each feature on a scale of one to four, and nine tenths of patients scored their experiences of care received. We calculated the potential for improvement by multiplying the proportion of negative patient experiences with the mean importance score in each country. Scores were divided into low, medium and high improvement potential. Pair-wise correlations were made between improvement scores and three dimensions of the structure of primary care – governance, economic conditions and workforce development.

Findings

In 26 countries, one or more features of primary care had medium or high improvement potentials. Comprehensiveness of care had medium to high improvement potential in 23 of 34 countries. In all countries, doctor–patient communication had low improvement potential. An overall stronger structure of primary care was correlated with a lower potential for improvement of continuity and comprehensiveness of care. In countries with stronger primary care governance patients perceived less potential to improve the continuity of care. Countries with better economic conditions for primary care had less potential for improvement of all features of person-focused care.

Conclusion

In countries with a stronger primary care structure, patients perceived that primary care had less potential for improvement.     

Practice variation in the Dutch long‐term care and the role of supply‐sensitive care: Is access to the Dutch long‐term care equitable?

Universal access and generous coverage are important goals of the Dutch long‐term care (LTC) system. It is a legal requirement that everyone eligible for LTC should be able to receive it. Institutional care (IC) made up for 90% of Dutch LTC spending. To investigate whether access to IC is as equitable as the Dutch government aspires, we explored practice variation in entitlements to IC across Dutch regions. We used a unique dataset that included all individual applications for Dutch LTC in January 2010–December 2013 (N = 3,373,358). This dataset enabled an accurate identification of the need for care. We examined the local variation in the probability of being granted long‐term IC and in the intensity of the care granted given that individuals have applied for LTC. We also investigated whether the variation observed was related to differences in the local availability of care facilities. Although our analyses indicated the presence of some practice variation, its magnitude was very small by national and international standards (up to 3%). Only a minor part of the practice variation could be accounted for by local supply differences in care facilities. Overall, we conclude that, unlike many other developed countries, the Dutch system ensured equitable access to long‐term IC.     

Aiding priority setting in health care: is there a role for the contingent valuation method?

The paper discusses some methodological and measurement aspects with the contingent valuation (CV) method which appear to create problems when eliciting preferences for the relative social valuation of alternative health care programmes. After pointing to biases which tend to exaggerate the true valuations, emphasis is placed on framing issues when applied to health care. Thereafter the paper discusses the extent to which preferences elicited through one's willingness to pay can be used to infer how the respondent would prioritise between the health care programmes in question. New empirical evidence is presented which suggest discrepancies between a CV ranking and the ranking expressed when making a direct ordinal comparison. © 1997 John Wiley & Sons, Ltd.     

Predicting energy requirements in the clinical setting: are current methods evidence based?

Estimating energy requirements is necessary in clinical practice when indirect calorimetry is impractical. This paper systematically reviews current methods for estimating energy requirements. Conclusions include: there is discrepancy between the characteristics of populations upon which predictive equations are based and current populations; tools are not well understood; and patient care can be compromised by inappropriate application of the tools. Data comparing tools and methods are presented and issues for practitioners are discussed.     

Virtual communities of practice: can they support the prevention agenda in public health?

Background

Virtual Communities of Practice (CoPs) are flexible communication and knowledge management tools enabling collaboration, sharing of best practice and professional development. There have been few studies that have looked at the use and usefulness of virtual CoPs in public health.

Methods

This project sought to gather the evidence and develop recommendations for the value of virtual CoPs in public health through a literature review, and through piloting two CoPs in obesity. The research aimed to find out how useful CoPs are in obesity prevention, what makes a CoP successful and what evaluation methods are appropriate.

Results

CoPs are composed of observers, passive and active contributors with a small group of ''super-users''. All users learn through reading and listening, even if they do not post. The CoPs had higher levels of reading activity as opposed to low levels of posting activity. Longer existence of CoPs usually means more active membership. There are complex reasons why users fail to engage in knowledge sharing. Success of a CoP is creating an online environment where users feel comfortable. CoPs need administrative support and facilitation. Champions play a vital role.

Conclusions

Evidence shows some encouraging results about the value of CoPs in enabling collaboration and information sharing. Despite low membership numbers of the obesity CoPs piloted, members see value and suggest improvements. Findings suggest that success comes from leadership, champions, and larger networks with more posting activity. Mixed methods of quantitative and qualitative research are appropriate in measuring the use and impact of CoPs.     

Preferences for ‘life‐saving’ programmes: Small for all or gambling for the prize?

Much of the literature on the value of life is based on the valuation of small reductions in mortality risk with many remaining life years if the fatal outcome is avoided. In contrast, this paper explores valuations of interventions which with varying probability levels offer smaller or moderate life year health gains. We interviewed 2900 respondents about hypothetical therapies that involved life year gains in the range of 1-180 months with a probability of 1 to 1/180, presented both in individual and societal perspectives. The results of the study indicate that the value of the hypothetical treatments is not a simple function of probability and gain. Rather, respondents seem to adopt thresholds when they value treatment offers. This results in kinked utility functions where the expected individual utility is significantly decreased when the gain in life expectancy is 6 months or less, and markedly increased if the probability of gains exceeds 1/12. There were only small differences in valuations across the individual and societal perspectives, suggesting that preferences for dispersion of health gains are not only a reflection of equity considerations. If the results of this study reflect widespread preferences, the standard methods in cost-effectiveness/cost-utility analysis may misinform decision makers.     

Self‐care as care left undone? The ethics of the self‐care agenda in contemporary healthcare policy

Self‐care, or self‐management, is presented in healthcare policy as a precursor to patient empowerment and improved patient outcomes. Alternatively, critiques of the self‐care agenda suggest that it represents an over‐reliance on individual autonomy and responsibility, without adequate support, whereby ‘self‐care’ is potentially unachievable and becomes ‘care left undone’. In this sense, self‐care contributes to a blame culture where ill‐health is attributed to personal behaviours or lack thereof. Furthermore, self‐care may represent a covert form of rationing, as the fiscal means to enable effective self‐care and supplement, or replace, self‐care capacities, is not provided. This paper explores these arguments through a contemporary ethical analysis of the self‐care agenda. The terms self‐care and self‐management are used interchangeably throughout whereby self‐management is understood as a point in the wider self‐care continuum.