Quality of Life Therapy and Assessment in Health Care

An integrative model of quality of life is proposed as a way to correct for terminological inconsistencies and to guide further quality of life research and health care applications. Research and theory supporting the need for routine quality of life assessment and intervention in general medicine, psychiatry, clinical psychology, behavioral medicine, and gerontology are discussed. Clinical guidelines for and research on quality of life assessment and intervention in health care are presented and reviewed. An integrated service delivery system in which quality of life assessments and interventions are considered coequal with those aimed at ameliorating physical and psychological symptoms is proposed along with a future program of research.     

Psychosocial stress and cardiovascular disease. Part 3: Clinical and policy implications of research on the transcendental meditation program

Cardiovascular disease (CVD) remains the leading cause of death in the United States today and a major contributor to total health care costs. Psychosocial stress has been implicated in CVD, and psychosocial approaches to primary and secondary prevention are gaining research support. This third article in the series on psychosocial stress and CVD continues the evaluation of one such approach, the Maharishi Transcendental Meditation program, a psychophysiological approach from the Vedic tradition that is systematically taught by qualified teachers throughout the world. Evidence suggests not only that this program can provide benefits in prevention but also that it may reduce CVD-related and other health care expenses. On the basis of data from the studies available to date, the Transcendental Meditation program may be responsible for reductions of 80% or greater in medical insurance claims and payments to physicians. This article evaluates the implications of research on the Transcendental Meditation program for health care policy and for large-scale clinical implementation of the program. The Transcendental Meditation program can be used by individuals of any ethnic or cultural background, and compliance with the practice regimen is generally high. The main steps necessary for wider adoption appear to be: (1) educating health care providers and patients about the nature and expected benefits of the program, and (2) adjustments in public policies at the state and national levels to allow this program to be included in private and public health insurance plans.     

Development of a multidisciplinary primary care program at the Drew University of Medicine and Science.

This article describes a required primary care curriculum for all third and fourth year medical students at the Drew/UCLA Medical Education Program. The curriculum is a supplement to the traditional medical school clinical requirements. Key features of the primary care core curriculum in the third year include a weekly half-day multidepartmental continuity clinic in a community health center serving underrepresented minority populations, a weekly didactic conference on primary care and society, a weekly clinical workshop on primary care skills, a weekly case review conference, and an orientation to primary care research methods. Fourth year medical students select a primary care subinternship that extends half days for 10 weeks in a community-based ambulatory care clinic. Fourth-year students also are required to select a mentor and conduct a research project on a primary care topic. Continuity of care records suggest that this program has been successful in allowing medical students to assume primary responsibility for a set of patients and to maintain significant levels of continuity of care over the course of the year. The evolution of the program, problems encountered, and anticipated changes in the curriculum are discussed.     

Dental patient education: self-care to healthy human development

Credited with a long history of providing preventive care, dentists are challenged by increasing demands from better educated consumers interested in improving their health and caring for themselves. The task of administering patient education services, identifying patients at risk, targeting specific behaviors for change, and managing costs is the subject of this case study. The Self-Care Motivation Model described here, is used to develop a patient education/smoking cessation/lifestyle change program for a patient with numerous dental and general health disturbances. Time and cost saving methods for administering such total patient care are discussed. Suggestions for reframing the context of dental patient education and health behavior change initiatives to include general healthy human development competencies are provided.     

Quality assurance, standards and criteria in health education: a review.

The necessity for health-education program development and implementation to follow principles of quality assurance is discussed. Sound principles of health education practice need to be followed for delivery of quality health education services. The integration of health education and quality assurance in medical care is promoted as an example of activities that may be interdependent with greater relevance together than either approach alone. Examples of standards and criteria for health education are provided. A case is made for the promotion of quality assurance activities for health education practice.     

Working across the boundaries of health professions disciplines in education, research, and service: the University of Washington experience.

The Institute of Medicine's vision for health professions education specifies working together across professions and schools to provide patient-centered care. Improvement in collaborative preparation of health professionals is seen as central to achieving substantial improvement in the quality of health care. In this article, the authors address one central question: How can medical schools work with other health-sciences schools to promote their educational, research, and service missions? The authors summarize the history of the University of Washington (UW) Health Sciences Center in promoting interprofessional collaboration in education, service and research; analyze the key strategic, structural, cultural and technical elements that have promoted success or served as barriers in the development of the UW Center for Health Sciences Interprofessional Education and Research; and suggest strategies that may be transferable to other institutions seeking to implement an interprofessional health sciences program. These include both top-down and bottom-up authority and function in key working groups, institutional policies such as interprofessional course numbers and shared indirect costs, and development of a culture of interprofessionalism among faculty and students across program boundaries.     

Diabetes and behavioral medicine: the second decade

Diabetes management depends almost entirely on behavioral self-regulation. Behavioral scientists have continued a collaboration with other health systems researchers to develop a holistic approach to this disease. The authors summarized the literature in 4 major areas: self-management of diabetes, psychosocial adjustment and quality of life, neuropsychological impact, and psychobehavioral intervention development. Progress made in each of these areas over the past decade is highlighted, as are important issues that have not yet received sufficient scientific attention. Emerging areas likely to become central in behavioral research, such as diabetes prevention, are introduced. The future of behavioral medicine in diabetes is also discussed, including topics such as the changing role of psychologists in diabetes care, the urgent need for more and better intervention research, the growing importance of incorporating a health system-public health perspective, and obstacles to the integration of psychobehavioral approaches into routine health care delivery.     

Examining the evidence of the impact of health information technology in primary care: An argument for participatory research with health professionals and patients

PurposeHealth information technology represents a promising avenue to improve health care delivery. How can we use lessons learnt from existing health information technologies in primary care to inform the optimal design of newer developments such as personal health records?MethodsThe results of systematic literature reviews about the impact of different information systems on health outcomes in primary care are critically discussed in a narrative synthesis, with a focus on their implications for the development of personal health records.ResultsGiven the proliferation of systematic reviews and randomized controlled trials, high quality evidence for health information technology in primary care is accumulating with mixed results. The heterogeneity of systems being compared and the quality of research can no longer account for these findings. One potential explanation may be that systems originally designed for acute care settings are being implemented in primary care. Early studies evaluating personal health records suggest that targeting patient outcomes directly and adapting systems to patients’ needs may be part of the solution.ConclusionIn order to develop personal health records for primary care, studies are needed that involve the users, namely patients and primary care health professionals, in the design and evaluation of these systems from their inception. Participatory research is a recommended methodological approach.     

Laboratory medicine in the compulsory postgraduate clinical training system--newly revised program in Nihon University School of Medicine

In 1999, the 4th report of the discussion group on 21st century medicine and health care proposed that it was necessary to establish in medical education a core curriculum emphasizing carefully selected basic content and to greatly expand the number of subjects that students might take electively. Following this report, a model core curriculum was made by the research and development project committee for medical educational programs in 2001. Similarly, the necessity of establishing a standardized postgraduate training curriculum and system has been discussed for many years. The Departments of Education and Technology and Welfare and Labor proposed a new curriculum named "Objectives in postgraduate clinical training" in order to ensure the quality of the medical doctors licensed to practice medicine in postgraduate clinical training in 2002. Following this new curriculum, Nihon University School of Medicine revised and enlarged its postgraduate program. All graduates are required to enter a full rotation program including general disciplines for two years. In addition to this basic curriculum, an elective curriculum will be added, providing attractive training programs based on medical trainees' needs. The training program in Laboratory Medicine is administered in the 2nd year as an elective program.     

Feasibility of encoding the Institute for Clinical Systems Improvement Depression Guideline using the Omaha System

Evidence-based clinical guidelines are being developed to bridge the gap between research and practice with the goals of improving health care quality and population health. However, disseminating, implementing, and ensuring ongoing use of clinical guidelines in practice settings is challenging. The purpose of this study was to demonstrate the feasibility of encoding evidence-based clinical guidelines using the Omaha System. Clinical documentation with Omaha System-encoded guidelines generates individualized, meaningful data suitable for program evaluation and health care quality research. The use of encoded guidelines within the electronic health record has potential to reinforce use of guidelines, and thus improve health care quality and population health. Research using Omaha System data generated by clinicians has potential to discover new knowledge related to guideline use and effectiveness.     

Preventive work in family medicine--proactive approach

The role of general practitioner/family physician (GP/FP) in disease prevention and health promotion is strongly supported by research and health policies. The position of GPs/FPs in the health care system and their close, sustained contact with their patients and local community makes preventive care an integral part of GP/FP routine work. The spectrum of caring for patients in general practice/family medicine is actually very large, going from intervention on health care determinants to palliative care. The prevention-related activities are more or less present at each step of this "healthcare continuum". The significant gaps between GP/FP knowledge and practices persist in the use of evidence-based recommendations for health promotion and disease prevention. We describe the role of GP/FP in preventive care and report data on preventive care activities in the Croatian Family Medicine Service. More objective evidence is needed to see what GPs/FPs actually do in practice. For this reason, it is critical that GPs/FPs systematically record the most relevant preventive and health promotion activities that they perform. Furthermore, their performance of the preventive program should be regularly monitored, evaluated and professionally and financially validated. We present the preventive program based on these principles in Family Medicine Service proposed by the Ministry of Health and Social Welfare Working Group on Reform of Primary Health Care.     

The current status and future of VA research

The VA Advisory Committee for Health Research Policy concluded that the health research aspect of departmental operations is vital to the VA's continued ability to provide high-quality health and medical care. The quality of VA-sponsored research in all areas remains high and on a par with that supported by the NIH and other governmental agencies sponsoring health research. Recent decreases in the financial support of VA research, however, have led to the unwise curtailment of VACO research staff support for this program, have reduced the number of approved projects that can be funded (though there has been a fourfold increase in the number of approved but unfunded projects), and are likely to reduce the attractiveness of VA employment for highly qualified physicians. In view of these findings, the committee recommended several steps that, if found feasible and taken soon, would both restore the long-standing stature of VA research and assure the attractiveness of VA careers for the many clinician-investigators upon whom the VA's quality of patient care necessarily depends.     

The U.S. health care system: challenges for the academic health professions community.

The author discusses the need to create structural reforms in the nation's health care system, built around a consensus on workable, affordable solutions, the first of four needs in this area, and presents a set of principles that must frame the debate on health care reform (e.g., that health care must be accessible to all Americans). He also presents practical options that address the United States' most urgent health care concerns (e.g., making the cost of health insurance more affordable for small businesses). The second need is to preserve and strengthen the nation's biomedical research enterprise; the author outlines steps that are already under way to deal with this need (e.g., the development of a Biomedical Research Initiative in the Public Health Service and the allocation of funds for various research-connected activities). The third need is to increase the participation of minority youth in science and the health professions; the author outlines steps that are being taken to encourage such participation (e.g., helping historically black colleges and universities and funding training programs for training minority professionals in health care). The last need discussed is to foster a culture of character: empowering citizens to take control of their own lives to eliminate costly debilitating illness before it strikes. For all these needs to be addressed successfully, it is crucial that the involvement of the academic health professions community and the community at large be expanded.     

An innovative clerkship module focused on patients with disabilities

Lack of medical training results in physicians being unprepared to provide care to people with disabilities, which, in turn, contributes to the substantial health disparities that are evident in this population. Few medical schools or primary care residencies address the care of adults with disabilities. Competencies and guidelines to assist American physicians in caring for patients with physical or intellectual disabilities have yet to be established, thus making educational goals unclear. This article describes one novel training module regarding people with disabilities that was developed at the University of South Florida Health, Morsani College of Medicine (USF) and inserted into the primary care clerkship during a major curriculum redesign in 2005. Since then, all USF third-year medical students have been required to participate in this disability-related course component. The authors describe the module's development and integration into the primary care clerkship, as well as the specific elements of their curriculum. By using a variety of teaching modalities in the classroom and community, and especially by involving people with disabilities themselves, the medical students have a very comprehensive learning experience regarding people who have physical, sensory, or intellectual disabilities. The authors have been able to show that USF medical students, on completion of this module, demonstrate improved knowledge, attitudes, and comfort in caring for people with disabilities, which the authors believe will lead to improved health and health care access for this underserved population. Suggestions for program replication, including common challenges, are also discussed.     

Development and implementation of an online master's degree in education program for health care professionals.

Technological advances, especially the Internet and the World Wide Web, have drastically changed educational practices by reforming the concept of education and knowledge transmission at a distance. Professionals in all disciplines have begun using this advanced technology to expand the number of learning opportunities for intellectual growth and professional development. As a result, many universities and educational institutions now offer online higher degree programs to provide opportunities for nontraditional students who have difficulty attending scheduled, campus-based classes. In medicine, a need has been identified for advanced graduate studies in education to develop the next generation of medical educators and to train them in educational research methods to validate their educational efforts. This need was identified by both informal needs assessment at local, regional, and national faculty development meetings and more formal literature review and government survey. The faculty development team of Cincinnati Children's Hospital Medical Center (Department of Pediatrics, University of Cincinnati College of Medicine) collaborated with the College of Education to develop an online Master's Degree in Education for health care professionals. The program was designed to apply these advanced technologies in order to make the program flexible and accessible to health care professionals whose busy schedules preclude more traditional, in-class graduate programs. This article presents how this program evolved and the problems, challenges, and solutions associated with the development and implementation of the program.     

Practical clinical behavioral treatment of obesity

The objective was to create a method/model that works in practical clinical treatment for health care personnel as well as for the patients, to educate and supervise health care staff according to this model and to initiate long-term treatment of obese patients in a health care setting. The hypothesis was that it is possible to successfully initiate behavior-modified treatment in the form of a structured treatment program as a method and a tool adapted to use in health care. The aim of this article is to describe an extensive structural cognitive behavioral treatment program for patients. The treatment program is documented in a handbook for supervisors and a self-monitoring book for patients. This handbook is used in the education of the health care personnel and supports the supervisor in the clinical work with the patients. The main purpose of all individual or group treatment is to bring about reduction of body weight or weight control. To obtain weight control through lifestyle changes a balance has to be found between eating behavior, physical activity and body weight control. To reach this kind of balance it is important to have treatment programs where the aim and goals are clearly declared. The structure and the content of the program shall motivate and create interest for changes in the overweight person's behavior. This treatment program includes a schematic survey and an example of a structured treatment program. Over the last few years, 850 nurses, dietitians and other health care personnel have been educated, representing 400 primary health care centers and hospitals within Sweden. Overall these participants find their education and supervision meaningful and valuable.     

The development and preliminary evaluation of a decision aid based on decision analysis for two treatment conditions: benign prostatic hyperplasia and hypertension

This paper discusses the development and evaluation of a computerised decision aid that provides individualised information about Benign Prostatic Hyperplasia (BPH) and Hypertension to patients. The program is based on decision analysis, using decision trees as a way of providing users with information regarding the probability of different outcomes occurring, obtaining an individual evaluation of the different outcomes, before providing guidance on what might be the 'best' option for that patient. It is intended that the program can be used as the basis for helping patients to become more involved in decisions about their medical treatment. Eight health care professionals and 19 patients (9 with BPH and 10 with Hypertension) evaluated the program. Overall it was assessed positively by both health care professionals and patients. However, before it can be integrated into health care practice, the program is to be evaluated further in a randomised trial.     

Visions and strategies to improve evaluation of health information systems. Reflections and lessons based on the HIS-EVAL workshop in Innsbruck

BACKGROUND: Health care is entering the Information Society. It is evident that the use of modern information and communication technology offers tremendous opportunities to improve health care. However, there are also hazards associated with information technology in health care. Evaluation is a means to assess the quality, value, effects and impacts of information technology and applications in the health care environment, to improve health information applications and to enable the emergence of an evidence-based health informatics profession and practice. OBJECTIVE: In order to identify and address the frequent problems of getting evaluation understood and recognised, to promote transdisciplinary exchange within evaluation research, and to promote European cooperation, the Exploratory Workshop on "New Approaches to the Systematic Evaluation of Health Information Systems" (HIS-EVAL) was organized by the University for Health Sciences, Medical Informatics and Technology (UMIT), Innsbruck, Austria, in April 2003 with sponsorship from the European Science Foundation (ESF). Methods: The overall program was structured in three main parts: (a). discussion of problems and barriers to evaluation; (b). defining our visions and strategies with regard to evaluation of health information systems; and (c). organizing short-term and long-term activities to reach those visions and strategies. RESULTS: The workshop participants agreed on the Declaration of Innsbruck (see ), comprising four observations and 12 recommendations with regard to evaluation of health information systems. Future activities comprise European networking as well as the development of guidelines and standards for evaluation studies. CONCLUSION: The HIS-EVAL workshop was intended to be the starting point for setting up a network of European scientists working on evaluation of health information systems, to obtain synergy effects by combining the research traditions from different evaluation fields, leading to a new dimension and collaboration on further research on information systems' evaluation.     

Psychological preparation for pediatric hospitalization

Researchers and health care providers have given much attention to various aspects of preparing children for hospitalisation and surgery. This paper reviews the empirical and nonempirical literature from a multidisciplinary viewpoint, including some aspects neglected in previous reviews. Research and program reports on preparation themes, preparation media, timing and length of preparation, primary prevention approaches, and patient characteristics are outlined and discussed. Finally, the paper examines the research validation of preparation procedures as used in empirical studies and in actual practice. A case is made for multidimensional assessment of treatment effects and for ecological validity of research-based procedures. The extensive research and reports reviewed throughout this article point to specific questions to be resolved by further investigation and application.     

Health information systems - past, present, future

In 1984, Peter Reichertz gave a lecture on the past, present and future of hospital information systems. In the meantime, there has been a tremendous progress in medicine as well as in informatics. One important benefit of this progress is that our life expectancy is nowadays significantly higher than it would have been even some few decades ago. This progress, leading to aging societies, is of influence to the organization of health care and to the future development of its information systems. Twenty years later, referring to Peter Reichertz' lecture, but now considering health information systems (HIS), two questions are discussed: which were lines of development in health information systems from the past until today? What are consequences for health information systems in the future? The following lines of development for HIS were considered as important: (1) the shift from paper-based to computer-based processing and storage, as well as the increase of data in health care settings; (2) the shift from institution-centered departmental and, later, hospital information systems towards regional and global HIS; (3) the inclusion of patients and health consumers as HIS users, besides health care professionals and administrators; (4) the use of HIS data not only for patient care and administrative purposes, but also for health care planning as well as clinical and epidemiological research; (5) the shift from focusing mainly on technical HIS problems to those of change management as well as of strategic information management; (6) the shift from mainly alpha-numeric data in HIS to images and now also to data on the molecular level; (7) the steady increase of new technologies to be included, now starting to include ubiquitous computing environments and sensor-based technologies for health monitoring. As consequences for HIS in the future, first the need for institutional and (inter-) national HIS-strategies is seen, second the need to explore new (transinstitutional) HIS architectural styles, third the need for education in health informatics and/or biomedical informatics, including appropriate knowledge and skills on HIS. As these new HIS are urgently needed for reorganizing health care in an aging society, as last consequence the need for research around HIS is seen. Research should include the development and investigation of appropriate transinstitutional information system architectures, of adequate methods for strategic information management, of methods for modeling and evaluating HIS, the development and investigation of comprehensive electronic patient records, providing appropriate access for health care professionals as well as for patients, in the broad sense as described here, e.g. including home care and health monitoring facilities. Comparing the world in 1984 and in 2004, we have to recognize that we imperceptibly, stepwise arrived at a new world. HIS have become one of the most challenging and promising fields of research, education and practice for medical informatics, with significant benefits to medicine and health care in general.