Securing wide appreciation of health statistics

All the authors are agreed on the need for a certain publicizing of health statistics, but do Amaral Pyrrait points out that the medical profession prefers to convince itself rather than to be convinced. While there is great utility in articles and reviews in the professional press (especially for paramedical personnel) Aubenque, de Groot, and Kohn show how appreciation can effectively be secured by making statistics more easily understandable to the non-expert by, for instance, including readable commentaries in official publications, simplifying charts and tables, and preparing simple manuals on statistical methods. Aubenque and Kohn also stress the importance of linking health statistics to other economic and social information. Benjamin suggests that the principles of market research could to advantage be applied to health statistics to determine the precise needs of the "consumers". At the same time, Aubenque points out that the value of the ultimate results must be clear to those who provide the data; for this, Kohn suggests that the enumerators must know exactly what is wanted and why.There is general agreement that some explanation of statistical methods and their uses should be given in the curricula of medical schools and that lectures and postgraduate courses should be arranged for practising physicians.     

Software for tabular data protection

In order for national statistical offices to maintain the trust of the public to collect data and publish statistics of importance to society and decision-making, it is imperative that respondents (persons or establishments) be guaranteed privacy and confidentiality in return for providing requested confidential data. Consequently, for most survey and census data, disclosure limitation techniques must be applied before the data are ready for public release. For microdata, examples of methods that can be used to identify respondents include directly extracting identifying information from microdata files or indirectly identifying respondents by matching a given file with an external file. For tabular data, respondents may be identified directly from small cell counts or respondent contributions to heavily concentrated cells of magnitude data may be closely approximated by the cell value. Indirect disclosure is possible in tables through manipulation of additive tabular relationships between cell values and totals, e.g. manipulating rows and column totals in a two-dimensional table. Two-dimensional statistical tables are a staple of official statistics. This paper describes a desktop software system that for the first time implements within a single framework four standard disclosure limitation techniques for protecting tabular data in two-dimensional tables: complementary cell suppression, minimum-distance controlled rounding, unbiased controlled rounding, and controlled rounding subject to subtotals constraints, and a fifth, new method: controlled tabular adjustment, and summarizes the five methods.     

Process management: two control charts

It is not at all surprising that many persons avoid involvement in statistical process control. The statistical procedures developed in industry to monitor production processes are somewhat different from those employed in biostatistics and social science applications. Many find it difficult to adjust to these procedures and to apply statistical process control techniques to situations in health care settings. Not everyone involved in a QI process, however, needs to become versed in statistical process control techniques. At the Indiana University Medical Center several persons from different hospital departments have volunteered to form a cadre of internal statistical process control consultants. The group has come to be known by some as the statistical process control "think tank." No doubt a small group of individuals who are interested in statistics, quality control, and computers can be found in most hospitals. While it is necessary that the large majority of managers and supervisors in any health care organization are knowledgeable about process management and control charts at the concept level of understanding, it takes a relatively few to understand and use such control charts. As internal consultants, these few persons can provide technical assistance when such aid is needed.     

The ethics of randomised controlled trials: A matter of statistical belief?

This paper outlines the approaches of two apparently competing schools of statistics. The criticisms made by supporters of Bayesian statistics about conventional Frequentist statistics are explained, and the Bayesian claim that their method enables research into new treatments without the need for clinical trials is examined in detail. Several further important issues are considered, including: the use of historical controls and data routinely collected on patients; balance in randomised trials; the possibility of giving information to patients; patient choice and patient autonomy; and how widely the results of clinical trials can be used. It is concluded that good statistical techniques in the design and analysis of medical studies are essential, but the statistical school used in developing such techniques is relatively unimportant.     

More safety for patients requires confidentiality in the enquiry into medical errors

Recently, a seven-month-old baby died after a cardiac intervention and a medical error was presumed. An independent committee investigated this mishap after the confidentiality of the report was guaranteed. However, because of a judicial ruling, the report had to be made public, which caused great upheaval. To improve safety, error management requires confidential investigation to ensure co-operation of all parties involved. There are two conflicting and irreconcilable aims: medical professionals want to establish what went wrong, legal professionals want to establish who is at fault. The position of investigative committees should be (legally) fortified with a guarantee of confidentiality and sound underlying principles of investigation should be delineated.     

Internalizing stigma associated with mental illness: findings from a general population survey in Jamaica.

OBJECTIVES: The culture of stigma associated with mental illness is particularly intense when persons who are normally victims of that stigmatization (mentally ill persons and their family members) themselves act negatively toward others whom they associate with mental illness. We attempt to determine the extent of this internalization and assimilation of stigmatizing attitudes, cognitions, and behaviors in persons who are at risk for such stigmatization in Jamaica. METHODS: Data from a 2006 national survey on mental health were analyzed. Demographic variables, the presence or absence of mental illness in respondents and in their family members, and responses pertaining to behaviors and attitudes toward mentally ill persons were examined. Subsamples (respondents with mental illness, respondents with a family member with mental illness, respondents with neither) were compared using the chi-square test. RESULTS: Respondents with family members with mental illness were less likely to demonstrate a number of different manifestations of stigmatization than others (P=0.009-0.019). Respondents with mental illness showed no difference in the demonstration of a number of different manifestations of stigmatization from other respondents (P=0.069-0.515). CONCLUSIONS: The small number of mentally ill respondents resulted in low statistical power for demonstrating differences between that subgroup and other respondents. The significantly more positive attitudes and behavior of respondents with family members with mental illness suggest that some benefit may be gained by creating more opportunities for the general public to interact with persons with mental illness.     

Informing and involving patients to improve the quality of medical decisions

Good-quality care requires that procedures, treatments, and tests be not only medically appropriate, but also desired by informed patients. Current evidence shows that most medical decisions are made by physicians with little input from patients. This article describes issues surrounding informed patient decision making and the steps necessary to improve the way decisions are made. Creating incentives for providers and health care organizations to inform patients and incorporate patients' goals into decisions is critical. Patient surveys are needed to monitor the quality of decision making. Health information technology can help by collecting information from patients about their symptoms, how well they understand their options, and what is important to them, and sharing that information with providers. We review public and private developments that could facilitate the development of tools and methods to improve patient-centered care.     

Statistics in medical journals

The general standard of statistics in medical journals is poor. This paper considers the reasons for this with illustrations of the types of error that are common. The consequences of incorrect statistics in published papers are discussed; these involve scientific and ethical issues. Suggestions are made about ways in which the standard of statistics may be improved. Particular emphasis is given to the necessity for medical journals to have proper statistical refereeing of submitted papers.     

The work-relatedness of disease: workers' own assessment

In the routine compilation of statistics on the relation between occupation and ill-health it is usually possible to demonstrate links to certain physically demanding occupations. However, studies of the causal links between work and ill-health present problems. Besides the difficulties that often occur in collecting information on present and previous occupations, exposure periods, latency, duration, etc, the analysis and interpretations themselves are complicated. The aim of this paper is to study the interviewees' own views on whether or not any ill-health they may suffer could be caused by any particular job they may hold or have held in the past. Does one get the same picture of the relationship between occupation and ill-health as when routinely compiling statistics? The study population comprised 12,664 men and 12,942 women between 25 and 75 years of age. For all respondents, detailed occupational histories were recorded The results indicated that health problems are more common among persons who have or have had physically demanding work. On the other hand, in certain heavy jobs with high numbers of persons reporting long-term illnesses it is rare for individuals to blame their health problems on working conditions. Conversely, other occupations have relatively low numbers of persons with long-term illnesses, yet high proportions of these attribute their health problems to their work.     

Can we make sense of multidisciplinary co‐operation in primary care by considering routines and rules?

Although it is widely acknowledged that the complex health problems of chronically ill and elderly persons require care provision across organisational and professional boundaries, achieving widespread multidisciplinary co-operation in primary care has proven problematic. We developed an explanation for this on the basis of the concepts of routines (patterns of behaviour) and rules, which form a relatively new yet promising perspective for studying co-operation in health-care. We used data about primary care providers situated in the Dutch region of Limburg, a region that, despite high numbers of chronically and elderly persons, has traditionally few healthcare centres and where multidisciplinary co-operation is limited. A qualitative study design was used, in which interviews and documents were the main data sources. Semi-structured interviews were conducted with providers from six primary care professions in the Dutch region of Limburg; relevant documents included co-operation agreements, annual reports and internal memos. To analyse the evidence, several data matrices were developed and all data were structured according to the main concepts under study, i.e. routines and rules. Although more research is needed, our study suggests that the emergence of more extensive multidisciplinary co-operation in primary care is hampered by the organisational rules and regulations prevailing in the sector. By emphasising individual care delivery rather than co-operation, these rules stimulate the perseverance of diversity between the routines by which providers perform their solo care delivery activities, rather than the creation of the amount of compatibility between those routines that is necessary for the current, rather limited shape of multidisciplinary co-operation to expand. Further research should attempt to validate this explanation by utilising a larger research population and systematically operationalising the rules existing in the legal and--more importantly--organisational environment of primary care.     

Co-operation as a strategy for provision of welfare services--a study of a rehabilitation project in Sweden

BACKGROUND: During the past 15 years, there have been many initiatives to improve the integration between different welfare agencies. This study is describing and analysing the co-operation between agencies involved in a rehabilitation project in Sweden, and discussing such inter-agency co-operation as a strategy for provision of complex welfare services. METHODS: The study is based on a process evaluation, where the co-operation between the agencies was followed and documented during the time of the project. Different kinds of data were collected through interviews, focus groups and diaries. The contents of these data were analysed in order to evaluate the process of co-operation. In addition, there was also an evaluation of the effects of the co-operation, based on official documents, statistics, etc. RESULTS: The evaluation shows that it was possible to co-operate across the organizational boundaries of the different agencies, but there were obstacles related to organizational and cultural differences of the agencies, divided loyalties of the officials and limited resources available to deal with the complex needs of the clients. At the same time, the commitment and the relations between the officials were facilitating the co-operation. DISCUSSION: Based on the evaluation of this project, it seems that co-operation could be an effective strategy to deal with clients who need services from different welfare agencies. At the same time, however, it is clear that inter-agency co-operation requires a lot of time and energy and should therefore be used with caution.     

Selbsthilfe im GesundheitswesenStand der Forschung und Forschungsbedarf

Health related self-help groups and organisations make an important contribution to the health of the public in Germany. In particular self-help groups increase mutual aid and social support, knowledge about the disease and its consequences and possibilities for changing attitudes of the group members and their social environment. They disburden the primary social networks and families of the afflicted persons and reinforce the ‘intelligent’ use of professional services within the health care system. To date, virtually no systematic investigations concerning the activities of self-help organisations, apart from counselling services, have been carried out. Financial contributions from the social security system to self-help groups and organisations are increasing and they are becoming more and more an integral part of the health care system. However, the co-operation between self-help initiatives and the professional health care system is characterised by an imbalance between medical laymen and experts. Research in this area is fragmented; further investigations should address the questions of how larger proportions of the population can be involved in self-help activities and how the relevance of self-help differs in various patient groups. Research promotion and co-ordination in this area appear to be necessary.     

家庭远程康复在脑卒中康复护理中的应用进展

目的 分析国内外医院人力资源管理的研究现状与发展态势，为我国医院人力资源管理提供参考。方法 以国内外医院人力资源管理的文献为样本，对文献数量、研究地域、高产作者、研究热点以及研究前沿趋势等进行了多视角统计和可视化分析。结果 关于医院人力资源管理发文量最大的是美国；国内外发文量最多的机构分别是拉筹伯大学和丰县中医医院；国内的研究热点主要集中在人力资源管理的问题与对策、激励与绩效，并向信息化研究发展；国外的研究热点集中在医护人员的工作满意度和医疗质量与安全，向激励和医学教育方向发展。结论 国内作者、机构之间应加强合作，需要引进国外的“人本”观念，运用信息系统提高医院人力资源管理效率。     

Florida doctors seeing Medicaid patients show broad interest in federal incentives for adopting electronic health records

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 aims to expand the use of electronic health records by offering financial incentives to physicians to fully adopt and implement them. We surveyed Florida physicians who deliver care to Medicaid participants to identify their interest in participating in the incentive program. More than 60 percent of all respondents expressed interest in applying for the incentives; of those already using electronic health record systems, 86 percent intend to apply for funding. This relatively high proportion of physicians creates the potential to reach the overall policy goals of the law. Among those not planning to seek incentives, common barriers--especially among nonusers of electronic health records--were "costs involved" (69 percent), "need more information about incentive program" (42 percent), and uncertainty about what system to purchase (42 percent). We suggest that these findings hold implications for the Regional Extension Centers working to help physicians achieve the federal meaningful-use criteria that are a condition of receiving the incentives. In particular, the centers should focus on providing physicians with information about costs of electronic health record systems.     

The family history in family practice: a questionnaire study

OBJECTIVES: Our aims were to investigate family medical history taking in general practice, and to evaluate the value attached to the family medical history as an aid to decision making in general practice. METHOD: A postal questionnaire survey was conducted among all 291 GPs working within the Calderdale and Kirklees Health Authority area. Each questionnaire was followed by a reminder. The main outcome measures were answers to questions on routine and opportunistic family history taking and a question about transmitting knowledge about genetic risk to other members of the family. Questions were also posed about the value attached to the family medical history as an aid to decision making. RESULTS: A total of 193 GPs returned the questionnaire (response rate 66.3%). On registration, 94.3% of GPs indicated that enquiries were made about a family history of coronary heart disease. Breast and colorectal cancer were specifically asked about by 48.4% and 30.7% of GPs, respectively. One-fifth of respondents indicated that they asked a general question about family medical history. A little over one-quarter of respondents indicated that they made opportunistic enquiries about the family history or suggested that the patient should inform other members of the family about possible risks. In the scenarios highlighted in this study, the majority of respondents felt that the family medical history had value as an aid to decision making. This was particularly the case for checking a patient's cholesterol (92.1%) and for initiating referrals in younger patients with possible cancer-related symptoms (three-quarters of respondents). CONCLUSION: GPs value the family medical history as an aid to decision making. Unfortunately, apart from enquiries about coronary heart disease, routine or opportunistic family history taking is not occurring in practice. Mechanisms need to be sought to extract information from the family medical history so that it can be more effectively used by GPs.      

乌鲁木齐市维吾尔族HIV感染者卫生服务需要、利用和医疗费用的调查

目的了解乌鲁木齐市维吾尔族艾滋病病毒(human immunodeficiency virus,HIV)感染者的卫生服务需要、利用和医疗费用,为制定维吾尔族HIV感染者相关政策和措施提供依据。方法采用自行设计的问卷对77例维吾尔族HIV感染者进行单独面访,同时收集相关的实验室结果和诊疗记录,所获资料采用Excel 2003录入和分析。结果乌鲁木齐市维吾尔族HIV感染者两周患病率为76.6%,慢性病患病率为46.8%;两周就诊率为75.3%,两周患者未就诊率为39.0%,58.3%因经济困难未就诊;住院率为31.2%,应住院而未住院比例为31.4%,因经济困难未住院的占72.7%;次均门诊医疗费用为121元,次均住院医疗费用为6 874元。结论乌鲁木齐市维吾尔族HIV感染者的卫生服务需要和利用量大,经济负担重,卫生部门应针对其卫生服务特点及早制定相应对策,建立医疗救助机制满足其卫生服务需求。