Primary health-care teams as adaptive organizations: exploring and explaining work variation using case studies in rural and urban Scotland.

It is acknowledged, internationally, that health-care practitioners' work differs between and urban areas. While several factors affect individual teams' activities, there is little understanding about how patterns of work evolve. Consideration of work in relation to local circumstances is important for training, devising contracts and redesigning services. Six case studies centred on Scottish rural and urban general practices were used to examine, in-depth, the activity of primary health-care teams. Quantitative workload data about patient contacts were collected over 24 months. Interviews and diaries revealed insightful qualitative data. Findings revealed that rural general practitioners and district nurses tended to conduct more consultations per practice patient compared with their urban counterparts. Conditions seen and work tasks varied between case study teams. Qualitative data suggested that the key reasons for variation were: local needs and circumstances; choices made about deployment of available time, team composition and the extent of access to other services. Primary care teams might be viewed as adaptive organization, with co-evolution of services produced by health professionals and local people. The study highlights limitations in the application of workload data and suggests that understanding the nature of work in relation to local circumstances is important in service redesign.     

Contracting-out health care services: a conceptual framework.

Contracting-out has become increasingly prominent in the health-care sector. It has been used in activities ranging from 'internal market' arrangements in which providers compete for funding from government payers to purchases of medical and non-medical inputs by service providers. While contracting-out arrangements for non-medical services have been widely adopted with apparent success, the contracting-out of medical services has met with criticism. Specifically, prominent 'market failures' have been identified which allegedly make contracting-out inefficient and even potentially disruptive to health care delivery. This paper presents and discusses a systematic framework for policymakers to identify and assess potential problems in contracting-out health care services, as well as some generic approaches to mitigating these potential problems. A key to the framework is the notion that conditions contributing to potential market failure problems can often be mitigated by policymakers, and that the strategic choices of policymakers in the 'first stage' of the contracting process should include an analysis of how the contracting-out environment can be changed to mitigate potential market failure problems.     

The quality of family relationships and use of maternal health-care services in India

Marital quality is well established as a determinant of health in Western contexts, yet the importance of relationship quality to health in non-Western contexts is largely limited to a focus on domestic violence. Using the Women's Reproductive Histories Survey, this study examines whether women with higher-quality family relationships are more likely than others to use maternal health-care services in Madhya Pradesh, India. Results show that among nuclear families, women with better marital relationships are more likely than others to use antenatal care services and to deliver in a health-care facility. Among joint families, women who have better relationships with their in-laws are more likely to use antenatal care services. The results further suggest that women's agency mediates some, but not all, of the effect of relationship quality on use of maternal health-care services.     

Versorgungsforschung aus Sicht der Bundesärztekammer unter Berücksichtigung kleinräumiger Analysen

As early as 2003, the German medical profession realized the necessity of not only forwarding medical research, but also analyzing the process of health care itself. Approved by a decision of the 108th German Medical Assembly in 2005, an initiative on health-care research paid by contributions of the medical profession was launched. Since then several projects have been supported with the results being published continuously. From the perspective of the German Medical Association, the success of the initiative also proves the effective approach of the scientific and medical communities’ self-administration. Although the current results from health-care research can be used to support health-care politics and decision making at a macro level, a focus on small-area analysis tends to be an intrinsic attribute of health-care research, keeping a local approach toward changes so as to obtain real effects. Without local settings and without data reflecting the local situation, the“last mile” of a health-care system, which is the core subject of health-care research, will not be comprehensible.     

What has influenced patient health‐care expenditures in Japan?: variables of age,death, length of stay,and medical care

This study considers variables related to health-care expenditures associated with aging and long-term hospitalization in Japan. We focused on daily per capita inpatient health-care expenditures, and examined the impact of inpatient characteristics such as sex, age, survived or deceased, length of stay, adult disease, and type of medical care received during the duration of each stay. We analyzed data from the Survey of Medical-Care Activities in Public Health Insurance by multinomial logistic regression analyses. Age of patient had little impact on per capita inpatient health-care expenditures per day. As regards length of stay, inpatient stays of 8-14 days had a little impact on health-care expenditures. This study suggested that these results might be due to the kind of medical care received. More research is needed to determine the appropriate medical services to reduce long-term hospitalization. In the last month of care for patients who died, medical examinations had a great influence on health-care expenditures. This study showed that increasing medical examinations in the end-of-life care needs further investigation.     

Home care as an alternative to hospitalization: a case study in Belgium

In Belgium, primary health care services are well developed. Their efficiency is, however, handicapped by a general lack of coordination at a local level. Recently, pilot projects have been conducted to improve the integration of the various activities related to the practice of family medicine and especially those activities associated with the home care of chronic diseases and disabilities of the elderly. In one municipality where the coordination of primary care services is organized from a health centre, a retrospective study was carried out to measure the possible effect of such coordination on the use of health services. Indicators of the use of medical services were measured before and after the establishment of the coordinating centre, and were compared with the evolution observed in control areas. It is shown that the establishment of a health centre and the coordination of existing activities do not result in an inflationary use of primary care services. Moreover, the use of secondary care services seems to be reduced, indicating a net benefit in terms of costs.     

Commoditization of the international teleradiology market

Telemedicine improves access to medical care. However, telemedicine will also increase market volatility because of its ability to stimulate price competition and the insidious way it shifts liability for providing medical services. To cope with increased volatility, other economic sectors have evolved commodities markets by making greater use of standardized forward/future contracts. In the past, the need for medical services to be produced and consumed locally and a lack of an objective definition for medical quality, prohibited the use of forward contracts for health-care services. However, telemedicine, and the increasing use of statistical definitions of medical quality now make standardized forward contracts for health-care services conceivable. Commoditization of teleradiology would offer several advantages including increasing market transparency, a mechanism for ensuring medical quality, and a means for bringing capital into the health-care sector. To reap the benefits of a commodities market in teleradiology, the key will be for market stakeholders to overcome their fear of the unknown in order to organize a central exchange.     

An active Grid infrastructure for elderly care

We propose a technique in which elderly people can be monitored non-intrusively. The information is kept in an 'active' health record which becomes alive when attention or action is necessary concerning the condition of the elderly person. The proposed system consists of three main components: a sensor/actor loop, sensor records and associated active services, and a Grid middleware platform. Information is captured in realtime within a collaborative health-care Grid. The Grid connects elderly people, caregivers and medical service providers in ways that reduce unnecessary calls on expensive medical services through an intermediate local service centre (which can be virtual) assisted with Internet communications and monitoring technologies. The proposal should support preventive health-care programmes for reducing the cost of caring for the elderly.     

An evaluation of satisfaction with telemedicine among health-care professionals

A survey was conducted among non-doctor health-care professionals in six rural counties in Missouri. The purpose of the survey was to establish baseline data to evaluate the effect of changes in the health-care sector, especially technology changes, on the job satisfaction, career satisfaction, relationships and communication activities of health professionals. The survey included three rural counties in which integrated telecommunication and interactive video telemedicine services were being installed, but before significant activities had begun, and three comparator counties without substantial integrated telecommunications infrastructure and telemedicine services. During a one-month study period, 1108 questionnaires were distributed. The total response rate was 50.1% (n = 555). Of the respondents, 30.3% indicated that technology in health-care was having a large effect on their work, although only 18.2% indicated that telemedicine and telecommunications were having a large effect. No systematic differences were found among the health professionals in the two communities at the time telemedicine equipment was being installed.     

Immigrants and equitable health-care delivery in rural areas

ABSTRACT: In response to settlement patterns in Australia, most immigrant specialist services and programs have been developed in metropolitan locations and large provincial cities. However, immigrants have also settled in smaller numbers in country locations. It is of concern, therefore, to consider how responsive and equitable health-care services can be delivered in country regions when immigrants do not reach the critical mass that would warrant the development of specialist services. This paper draws on a consultation conducted in South Australia to propose a way forward in linking country health services with local immigrant communities and immigrant specialist services in cities.     

Attitude of population and physicians to the organization of medical care in a city

The authors analyze the population self-estimations of the health status and opinions on the quality of services rendered at local health centers, attitude to medical care, and suggestions on improvement of medical service organization. Analysis of interviews with physicians showed their attitude to transfer from state public health to medical services with different types of property and their opinions on modern situation in public health management. The priority problems of public health and potentialities of improving the activities of treatment and prophylactic institutions of the city and the quality of services rendered to the population have been identified.     

Navigating the time-space context of HIV and AIDS: daily routines and access to care

Geographers have shown that daily activities and social networks are constrained by time-space, but there are also enabling facets or opportunities created by daily routines for accessing material and emotional resources, improving quality of life, and even challenging existing power relations. Time-geography in this paper is taken as a starting point to assess how individuals living with HIV and AIDS navigate the complex and often difficult time space contexts defining their access to services. The concept of time space windows of access is offered as a way to understand the opportunities created by daily routines and social network interaction even in highly marginalized social, economic, and political circumstances. Survey data and in-depth interviews conducted with a diverse group of persons living with HIV and AIDS are used to illustrate this conceptual argument. Results indicate that the time space characteristics of daily routines, such as frequency of activities, variety or heterogeneity in activities, and whether activities are self- or social network-oriented, serve to define the availability of temporal and spatial windows of access to services. In addition, daily routines seem to matter for specific types of services, and have a limited role to play in terms of primary medical services or those associated with basic needs. The implications of these findings for theorizing and for enhancing access to services are provided.     

国内外全科医生工作满意度研究综述

全科医生作为基层医疗卫生服务的主要提供者,其服务质量和水平的提升对增进居民健康具有重要意义,而工作满意度直接影响了其医疗过程,进而影响到整个基本医疗卫生服务的供给效率和质量。因此,笔者从全科医生工作满意度这一视角入手,通过文献梳理,比较分析国内外全科医生工作满意度的测量工具、满意度水平和影响因素,从而对全科医生工作满意度的研究现状进行综述。研究发现国内全科医生工作满意度研究方法单一、内容趋于一致。在影响因素的研究中需进一步考虑加入工作自主性、工作多样性、客观工作环境等工作特征相关因素。在研究设计时考虑论证强度更高的纵向研究或队列研究。将研究结果与政策制定相结合,通过研究促进全科医生制度的完善。     

The present state of occupational medicine in Poland

Occupational medicine in Poland has a long tradition, dating back to the establishment of the first health-care institutions for industrial workers at an early stage of Poland's industrialization. Legal foundations of the industrial health-care system, based on the Soviet model, were enacted in 1953. During its most dynamic period of development (1970s and 1980s) the industrial health-care system provided medical services to about 6 million workers. The process of the political and economic transition in Poland began in 1989, and since 1991 there have been numerous transformations in the structure and function of industrial health services. The present article describes the main stages of the transformation process, occupational health training, research, advisory bodies, and the system for setting of hygienic standards. Received: 7 April 1996 / Accepted: 14 April 1997     

Educational posters and leaflets on leprosy: raising awareness of leprosy for health-care workers in rural South Africa

Leprosy is still occurring in the Republic of South Africa, but it has been eliminated as a public health problem. The country's leprosy care and control program is being provided as a primary health-care program within the general health-care services. Maintaining health workers' leprosy knowledge and awareness at the primary health-care level is one of the program's goals. In one of the country's rural areas, the availability of good-quality leprosy poster and leaflets at primary health-care facilities has been shown to contribute significantly to maintaining health workers' leprosy knowledge and awareness.     

Needs in rare diseases during paediatric age

All rare diseases present a common set of challenges to the sufferers and their families: diagnosis, dealing with symptoms, health information, obtaining helpful medical care, availability of medications, disability and emotional impact. Children with rare disorders are an important population from health care services, and social services perspectives, and families are providing long-term care for these chronically ill children. The impact of rare disorders in children is far-reaching, extending beyond the child to all those with whom he/she has contact. Multiple facets of life are affected including social an family relationships, economical well-being and activities of daily living. The assessment of needs for rare disorders treatment is a critical step in providing high quality care and achieving patients' and families' satisfaction. Findings from different studies show that people with rare diseases have medical and social needs. Social needs are becoming more relevant in developed countries where health care services, even with limitations, have greater availability than social services. Furthermore, it seems that health care and social services for persons with rare diseases need to be improved to address the patients' needs and to provide better support to families. Validated tools with good psychometric properties are still needed to assess quality of care on the basis of patients and family needs.     

RBRVS apprehension may be an administrative red herring

"The RBRVS has been accepted as a rational and systematic approach to determining fees for physician services. By adopting this method, the federal government has corrected the distorted incentive structure for physician payment, and has provided itself and others another tool with which to build an improved health-care system." The words of RBRVS architect and Harvard School of Public Health economist Dr. William C. Hsiao are receiving mixed reviews from health-care administrators and strategic planning consultants. While RBRVS is gaining some respect among health-care practitioners for lowering the cost of Medicare services, an unexpected ramification is developing. Many physicians are avoiding the administrative paperwork of another federal medical program by joining physician-hospital alliances where hospitals are luring physician fidelity with administrative incentives.     

Costs of dying: alternatives to rationing

In western industrialised countries, about 30% of health-care expenditure of retired people is incurred by individuals in their last year of life. The corresponding high costs of dying have led medical philosophers to ask for a rationing of health-care services according to age. By contrast, this paper pursues an individualistic approach. High costs of dying are identified as a consequence of moral hazard on both the demand and supply side of the health-care sector. Health insurance prevents demand for health-care services from decreasing when an individual's residual life expectancy shrinks. Age-related moral hazard can be limited by a coinsurance scheme with a deductible that increases with the age of the insured. Given the high costs of dying, the optimal insurance policy links the coinsurance rate to the age-specific mortality risk.     

Shifting the financial burden: the VA ambulatory care discharge policy.

The Department of Veterans Affairs is a primary source of health care services for many of the nation's uninsured and underinsured. Changes in congressionally mandated eligibility criteria and limited increases in appropriations have forced the Department to adopt a policy of discharging chronic but stable outpatients who have been treated for non-service-connected health conditions. Survey data from one VA medical center suggest that many, but not all, of those discharged: 1) have either Medicare or private insurance coverage; 2) have not sought or found alternative physician services in their local communities; 3) have discontinued taking previously prescribed medications; 4) report worsened health status since discharge; and, 5) have been hospitalized. In general, discharged patients from the lowest income group report the greatest financial access barriers. Preliminary analyses of the discharge policy suggest the potential for decreased access to needed medical services due to financial factors and cost-shifting from the VA to patients and other federal, state and local payers and providers.     

Utilization of health-care services at the end-of-life

End-of-life care poses a growing clinical and policy concern since most people who are dying utilize health-care services during this period of life. Hence, end-of-life care is a common and integral part of the care provided by health-care systems. There is a growing call for the implementation of a palliative approach as an integral part of all end-of-life care. The purpose of this study was thus to provide policy-makers, health-care providers and professional caregivers with increased knowledge about mainstream patterns of health-care utilization during end-of-life. The patterns of use of health-care services in a Swedish population who accessed the health-care system during their last 3 months of life were in this study examined through a retrospective examinations of medical and nursing records (n=229). We found high prevalences of use of both hospital care, primary care and care provided in people's homes and nearly three quarters of the persons included in the study used between two and three health-care services. However, the probability of using different health-care services was found to be strongly depending on demographic, social, functional and disease related characteristics. The study reveals a considerable use of different health-care services during end-of-life. It is hence essential to, on one hand delineate how such health-care services best can support people at the end-of-life, and on the other hand develop policies which facilitate the process of dying, both in hospitals as well as in peoples' homes. Implications for policy are discussed.