The morality of efficiency in health care--some uncomfortable implications.

There are some general considerations which have implications for the delivery and finance of health care in all countries, not only Canada and the USA. Beginning with two propositions: that access to health care is a right of citizenship, which should not depend on individual income and wealth; and that the objective of health services is to maximise the impact on the nation's health of the resources available; the paper examines the ethical justification for pursuing efficiency in health care provision. The different meanings of efficiency are discussed in detail, and the use of quantitative indicators of health benefit, such as the QALY, placed in context. It is argued that the determination of health care resource allocations should take account of costs at both the macro planning level and the micro level of the individual doctor-patient relationship. Given the starting points the overall conclusion is that it is ethical to be efficient, since to be inefficient implies failure to achieve the ethical objective of maximising health benefits from available resources.     

Incentives for cooperation in quality improvement among hospitals--the impact of the reimbursement system.

Up to now, few analytical models have studied the incentives for cooperation in quality improvements among hospitals. Only those dealing with reimbursement systems have shown that, from the point of view of individual or competing hospitals, retrospective reimbursement is more likely to encourage quality improvements than prospective financing, while the reverse holds for efficiency improvements. This paper studies the incentives to improve the quality of hospital care, in an analytical model, taking into account the possibility of cooperative agreements, price besides non-price (quality) competition and quality improvements that may simultaneously increase demand, increase or reduce costs and spill over to rival hospitals. In this setting quality improvement efforts rise with the rate of prospective reimbursement, while the impact of the rate of retrospective reimbursement is ambiguous, but likely to be negative for quality improvements that are highly cost-reducting and create large spillovers. Cooperation may lead to more or less quality improvement than non-cooperative conduct, depending on the magnitude of spillovers and the degree of product market competition, relative to the net effect of quality on profits and the share of costs that is reimbursed retrospectively. Finally, the stability of cooperative agreements, supported by grim trigger strategies, is shown to depend upon exactly the opposite interaction between these factors.     

Critical care nurses, ethical decision-making and stress

Considerable attention has focused on describing ethical issues that critical care nurses face in their practice; however, less attention has been directed at describing the process of ethical decision-making. Systematic research linking aspects of ethical-decision making and stress is lacking. This cross-sectional study examines the relationship between selected aspects of ethical decision-making, stress and selected nurse characteristics. Sixty-one critical care nurses completed the Nurse's Ethical Decision Making—ICU Questionnaire and the Health Professions Stress Inventory. Findings revealed that nurses who selected the patient advocacy model had significantly higher nurse autonomy scores, that perceived anxiety had a negative association with nurse autonomy, and that workplace restrictions and stress were related.     

Bacterial colonization and infection in an intensive care unit

One hundred and one patients, nursed in an intensive care unit for at least 24h, were monitored for bacterial colonization and infection. The infection rates were similar to those in other reports. Patients were not generally colonized with common environmental strains in the unit. Bacterial dissemination between patients was uncommon. No gentamicin resistant gram negative or Staphylococcus aureus strains were observed, nor methicillin resistant Staphylococcus aureus strains. the hypothesis that these favourable conditions are partly related to the excellent isolation and barrier nursing facilities in the unit cannot be fully substantiated.     

Disturbed behaviour in dementia sufferers: A comparison of three nursing home settings

In order to determine whether a specialist psychogeriatric nursing home was fulfilling its intended role of caring for the most behaviourally disturbed dementia sufferers, 24 of its demented residents were compared with 28 demented individuals discharged from a psychiatric unit to ordinary nursing homes and 30 mobile dementia sufferers in nursing home wards of a geriatric centre. Those in the psychogeriatric nursing home showed more disturbed behaviours than those in the other two settings. Scores on the Rating Scale for Aggressive Behaviour in the Elderly were compared with degree of cognitive impairment for the first time in the literature and showed no correlation with degree of cognitive impairment for the first time in the literature and showed no correlation with congnitive performance.     

lnter-rater reliability of an oral assessment guide for elderly patients residing in a rehabilitation ward

The aim of this study was to test the inter-rater reliability of a revised oral assessment guide (ROAG) for patients residing in a geriatric rehabilitation ward. A consecutive sample of 140 patients was recruited for the study. Oral assessments were performed for 133 newly admitted patients by one registered nurse (RN) during a period of six months. A dental hygienist (DH) carried out 103 oral assessments during the same half-year. For 66 patients, the RN and the DH performed independent assessments. There was an agreement between the RN and the DH in the majority of the independent assessments, except for tongue and teeth/dentures. The percentage agreement exceeded 80 percent. Inter-rater agreement measured by Cohen's Kappa coefficient ranged from moderate to very good and percentage agreement had a range of 58 to 91 percent. The agreement was highest in assessment of voice and swallowing (91%). Assessments of teeth and dentures seemed to be most difficult for the RN to evaluate. ROAG was found to be a clinically useful assessment tool. Additional education and training is needed to improve the reliability of the oral assessments and should include continuous support from a dental hygienist as well as a pictorial manual on how to use the ROAG.     

Alfentanil or fentanyl during isoflurane–based anaesthesia for day–care knee arthroscopy?

Forty patients agreed to participate in a study to compare whether fentanyl or alfentanil used as analgesic is associated with quicker recovery following anaesthesia for outpatient arthroscopy procedure. Psychomotor tests including choice reaction time (CRT), perceptive accuracy test (PAT) and finger tapping test (FTT) were done prior to induction of anaesthesia with propofol (2–3 mg–kg^-1). Patients were then divided into two groups: Group F (fentanyl) received 0.1 mg fentanyl prior to start of surgery and thereafter 0.05 mg every 30 min during the procedure. Group A (alfentanil) received 0.5 mg alfentanil prior to the onset of surgery and 0.25 mg every 15 min thereafter. Anaesthesia was then maintained using isoflurane (0.5–2%) in oxygen and air (Fio₂ 0.33) during spontaneous respiration with a face mask in a Bain's system. Psychomotor tests were repeated every 45 min postoperatively. Clinical recovery, visual analogue pain intensity score (VAS) and time to discharge home were also assessed by a nurse blind to the method used. Patients in Group A returned to baseline values on the FTT after 90 min while those in Group F did not return to baseline values until 135 min after the end of the operation. Clinical recovery and time to discharge home ("home ready") were also significantly longer in Group F. There was no difference in recovery as seen in the PAT and CRT between the groups. Also, there was no difference in the incidence of side effects and the pain intensity (VAS) scores were similar in the two groups at all time periods. We conclude that recovery following alfentanil is quicker compared to fentanyl when anaesthesia is based on isoflurane.