A patient in the clinic; a person in the world. Why shared decision making needs to center on the person rather than the medical encounter

Interest in shared decision making (SDM) has increased and become widely promoted. However, from both practical and measurement perspectives, SDM’s origin as an outgrowth of patient autonomy has resulted in narrowly conceptualizing and operationalizing decision making. The narrow focus on individual patient autonomy fails in four main ways: 1) excluding several facets of the roles, actions, and influences of decision partners in decision making; 2) focusing solely on the medical encounter; 3) ignoring the informational environment to which patients have access; and 4) treating each encounter as independent of all others. In addition to creating a research agenda that could answer important outstanding questions about how decisions are made and the consequences thereof, reconceiving SDM as centered on the person rather than the medical encounter has the potential to transform how illness is experienced by patients and families and how clinicians find meaning in their work.     

Impact of gestational age at delivery on the economics of triplet pregnancy

Objective: To establish the charges associated with triplet pregnancies managed at a single tertiary center, over a 5-year time period, and to evaluate the impact of prematurity on these charges.

Methods: All triplet pregnancies that reached at least 20 weeks gestation and received prenatal and neonatal care at our center from 1992 to 1996 were included. Charges for these mothers and neonates were extracted from two separate hospital billing computer systems, encompassing all inpatient, outpatient, technical, and professional charges. Linear regression was used to evaluate the relationship between gestational age at delivery and total charges.

Results: Fifty-five triplet pregnancies were included, resulting in the admission of 149 liveborn neonates. The median gestational age at delivery was 32.1 weeks. The mean charges per triplet mother were: $6,899 (professional), $3,959 (hospital outpatient), and $32,686 (hospital inpatient). The mean charges per neonatal sibling set were: $20,107 (professional) and $124,163 (hospital inpatient). The mean charges per complete triplet pregnancy was $187,814 (maternal plus neonatal). There was a significant inverse relationship between gestational age at delivery and total charges per triplet family, with a decrease of $16,584 for each additional gestational week reached (P = 0.006).

Conclusions: Triplet pregnancy charges averaged almost $190,000 each, which does not include charges associated with assisted reproductive technologies. These charges are almost all related to the expense of prolonged neonatal intensive care, and are significantly related to the gestational age at delivery. Efforts at containing these costs should focus on reducing the incidence of multiple gestation and preventing prematurity.     

STAFFING PATTERNS

Unsolved staffing pattern issues are viewed in the current context of funding pressures, third party payment, and management necessity for program and cost projections. Relevant factors are mustered for consideration with their implications. Use of differentiated skill levels and response as well as development of departmental services mandate are considered. The author also shares his experientially derived throughts on staff ratio to certain institutional assignments.     

Differences in the Scalability of Formal and Informal In-Home Care of Urban Elderly

Differences in the scalability of formal and informal in-home care to elderly are examined. A Guttman scale showed that exclusive use of informal in-home care was hierarchically scalable, but not when services were provided by any formal sources. There was some clustering of formal services, for example, a large number of those who received meals also used homemaker services. However, a large number of those who received nursing did not receive personal care. There was no overall pattern to the use of formal services. Implications of these findings as related to service planning and delivery are discussed.     

Caregiver Education and Support: Results of a Multi-Site Pilot in an HMO

ABSTRACT

Caregiver workshops were offered to members by a group practice HMO as part of a larger demonstration of adding community care to HMO services. Of 1,200 members indicating interest at four sites, 532 participated in workshops and 320 completed pre- and post-questionnaires on effectiveness. Analyses showed improvements in caregiving preparedness and reductions in sadness and depression. Engagement in the workshops (completing 3 or more sessions) and improvements were more likely for individuals with more independent lives and social capital. Alternative helping strategies are recommended for caregivers who are less likely to engage in classes due to burden or lack of respite or transportation.     

The Australian First‐time Grandparents Study: Time spent with the grandchild and its predictors

Aim: This paper presents data on the amount of contact a large cohort of first‐time Australian grandparents have with their grandchild, and the amount of child care they provide. It compares these with grandparents' expectations and desired levels. Method: Prospective grandparents were assessed on multiple measures before the birth of their grandchild, and at 6, 12, 24 and 36 months thereafter. Results: At the 12‐month assessment, grandmothers had approximately 15 hours per week contact, and provided approximately 7.5 hours per week of child care. The corresponding figures for grandfathers were 9.5 hours and 5 hours respectively. Approximately 10% of grandparents reported no contact with their grandchild, and 30–40% reported undertaking no child care. Almost half the grandparents desired more contact than they were actually getting. Conclusion: Accurate quantification of contact and care is a prerequisite for investigation of the impact of the transition to grandparenthood on health and well‐being.     

Views of general practitioners toward physiotherapy management of osteoarthritis—a qualitative study

ABSTRACT

Background: Osteoarthritis (OA) is a major cause of pain and physical disability, and general practitioners (GPs) are usually the first point of contact for patients. Physiotherapy has been shown as effective in the management of lower-limb OA. The aim was to explore the beliefs of GPs on the physiotherapy management of lower-limb OA in primary care. Methods: This is a qualitative study evaluating GP views about physiotherapy in Sheffield, South Yorkshire, UK. Participating GPs were recruited by systematic sampling, and invitation was given to GPs in 10 practices in the four localities in Sheffield. Semistructured interviews were completed and framework analysis was used to analyze the data. Results: Eight GPs were interviewed and six themes emerged from analysis of the data: perspective on OA, management strategy, views on patients, views on physiotherapy, working collaboratively, and suggestions for service improvements. GPs had a positive impression and knowledge of physiotherapy, but lacked understanding of the processes involved in treatment and limited awareness of clinical guidelines regarding the management of OA. Improvements in communication and collaborative working were critical issues suggested by the participants. Conclusion: This study found that GPs who were interviewed had a limited understanding on the role of physiotherapists and of clinical guidelines. Interprofessional communication was not as good as it should have been. A reconfiguration of the Sheffield musculoskeletal pathway may help achieve more effective collaborative working and a better outcome for patients.     

Effects of differential privacy techniques: Considerations for end users

We study the effects of differentially private (DP) noise injection techniques in a survey data setting, using the release of cost of early care and education estimates from the National Survey of Early Care and Education as a motivating example. As an example of how DP noise injection affects statistical estimates, our analysis compares the relative performance of DP techniques in the context of releasing estimates of means, medians, and regression coefficients. The results show that for many statistics, basic DP techniques show good performance provided that the privacy budget does not need to be split over too many estimates. Throughout, we show that small decisions, such as the number of bins in a histogram or the scaling of a variable in a regression equation, can have sometimes dramatic effects on the end results. Because of this, it is important to develop DP techniques with an eye towards the most important aspects of the data for end users.