Cost-effective Health Care System Research Articles

A Systematic Umbrella Review of the Effects of Teledentistry on Costs and Oral-Health Outcomes.

Teledentistry offers possibilities for improving efficiency and quality of care and supporting cost-effective healthcare systems. This umbrella review aims to synthesize existing systematic reviews on teledentistry and provide a summary of evidence of its clinical- and cost-effectiveness. A comprehensive search strategy involving various teledentistry-related terms, across seven databases, was conducted. Articles published until 24 April 2023 were considered. Two researchers independently reviewed titles, abstracts and full-text articles. The quality of the included reviews was critically appraised with the AMSTAR-2 checklist. Out of 749 studies identified, 10 were included in this umbrella review. Two reviews focusing on oral-health outcomes revealed that, despite positive findings, there is not yet enough evidence for the long-term clinical effectiveness of teledentistry. Ten reviews reported on economic evaluations or costs, indicating that teledentistry is cost-saving. However, these conclusions were based on assumptions due to insufficient evidence on cost-effectiveness. The main limitation of our umbrella review was the critically low quality of the included reviews according to AMSTAR-2 criteria, with many of these reviews basing their conclusions on low-quality studies. This highlights the need for high-quality experimental studies (e.g., RCTs, factorial designs, stepped-wedge designs, SMARTs and MRTs) to assess teledentistry's clinical- and cost-effectiveness.

National Analysis of Health care Related Costs for Health care Workers and Administrators Over the Past Decade: Toward Establishing Sustainable and Cost Effective Health care System.

We aim to investigate the costs associated with growth in the administrators, health care staff, and physicians to provide direction to establish a sustainable and cost-effective U.S. health care system. Data from the U.S. Bureau of Labor Statistics, particularly the Labor Force Statistics from the Current Population Survey, were utilized from 2009 to 2020. Wages and employment of medical and health service managers (administrators), health care practitioners and technical operations (health care staff), and physicians were used to calculate the total cost. Administrator wages have grown similarly to health care staff wages (-4.40 vs -3.01%, P = .454) and physician wages (-4.40 vs -3.29%, P = .672). Additionally, there has been a similar increase in health care staff employment (9.91 vs 14.23%, P = .269) and physician employment (9.91 vs 15.35%, P = .252) compared to administrator employment. Overall, the total growth in administrator cost is similar to the growth in total health care staff cost (6.23 vs 11.80, P = .104) and total physician cost (6.23 vs 13.02%, P = .079). In 2020, physicians had the highest employment growth but the smallest wage increase. Although health care staff experienced a greater percent growth in employment and cost per employee than administrators since 2009, the cost per administrator remains greater than that of health care staff. Understanding differences in wages and costs is essential to reduce health care spending without compromising access, delivery, and quality of health care services.

Learning to Lead: An Exploration of Leadership Development in Obstetrics and Gynaecology

Physicians’ leadership skills are essential to their ability to achieve high quality patient care and establish well-functioning, cost-effective healthcare systems. Research shows that effective physician leadership can improve clinical outcomes, including decreasing mortality rates and length of hospital stay. Despite its clear value, leadership training in residency and beyond is predominantly informal, and there is limited research regarding how leadership skills develop from training into independent practice.

The American Public Health Association Endorses Single-Payer Health System Reform.

Health care is a human right. Achieving universal health insurance coverage for all US residents requires significant system-wide reform. The most equitable and cost-effective health care system is a public, single-payer (SP) system. The rapid growth in national health expenditures can be addressed through a system that yields net savings over projected trends by eliminating profit and waste. With universal health insurance coverage through SP financing, providers can focus on optimizing delivery of services, rather than working within a system covered by payers who have incentives to limit costs regardless of benefit. Rather, with a SP, the people act as their own insurer through a partnership with provider organizations where tax dollars work for everyone. Consumer choice is then based on the best care to meet need with no out-of-pocket payments. SP financing is the best option to ensure equity, fairness, and public health priorities align with medical needs, providing incentives for wellness. Consumer choice will drive market forces, not provider network profits or insurer restrictions. This approach benefits public health, as everyone will have universal access to needed care, with treatment plans developed by providers based on what works best for the patient. In 2021, the American Public Health Association adopted a policy statement calling for comprehensive reforms to implement a SP system. The proposed action steps in this policy will help build a healthier nation, saving lives and reducing wasted health care expenditures while addressing inequities rooted in social, demographic, mental health, economic, and political determinants.

Comparative study on Vietnam’s and Philippines' COVID-19 response using historical institutionalism

PurposeThis paper analyzed the healthcare systems of the Philippines and Vietnam prior to the coronavirus disease 2019 (COVID-19) and their strategies on mass testing, contact tracing, quarantine procedures and information dissemination about the pandemic.Design/methodology/approachSteinmo's (2008) historical institutionalism approach was used in this paper. Secondary data gathering, document analysis and comparative process tracing were employed.FindingsThe findings revealed that Vietnam's implementation of its Law on Prevention and Control of Infectious Diseases in 2007, its relatively low-cost healthcare system, its efficient mass testing and contact tracing strategies and its science-based decisions are contributory to its success in handling the pandemic. Meanwhile, the Philippines failure to enact its Pandemic and All-Hazards Preparedness Act in 2013, its costly and dominantly private healthcare system, its heavy focus on strict, long lockdowns and its militarist methods to control the spread of the pandemic were found to be insufficient.Research limitations/implicationsDetailed study on the delivery of healthcare services in marginal areas, healthcare spending for COVID-19 positive individuals and information dissemination strategies about the pandemic were not explored.Practical implicationsHealth institutions can redesign their governance mechanisms by ensuring a cost-effective healthcare system and maximizing resource utilization to ensure efficient management of future pandemics. Moreover, national governments should not compromise their country's healthcare system over the economy during a pandemic.Originality/valueThis paper analyzed the countries' history of healthcare governance and its influence in handling COVID-19 compared to previous studies which only focused on the countries' strategies during the pandemic.

PharmActa: Personalized pharmaceutical care eHealth platform for patients and pharmacists.

Community pharmacists are critically placed in the patient care chain being an extended frontline within primary healthcare networks across Europe. They are trained to ensure safe and effective medication use, a crucial and responsible role, extending beyond the common misconception limited to just providing timely access to medicines for the population. Technology-wise, eHealth being committed to an effective, networked, patient-centered and accessible healthcare would prove a real asset in this direction by achieving improved therapy adherence with better outcomes and direct contribution to a cost-effective healthcare system. In this work, we present PharmActa, a personalized eHealth platform that addresses key features of pharmaceutical care and enhances communication of pharmacists with patients for optimizing pharmacotherapy. PharmActa empowers patients by providing pharmaceutical care services, such as drug interactions tools, reminders for assisting adhesion and compliance, information regarding adverse drug reactions, as well as pharmacovigilance along with related tools for healthcare management. In addition, it allows the pharmacists to review the medication history in order to provide personalized pharmaceutical care services; thus enhancing their role as healthcare providers. Finally, a mechanism allowing such a system to be interconnected with a developed medical repository following European and International interoperability standards, is also presented. Thus far, the evaluation results presented in this work indicate that PharmActa can be of great benefit to healthcare professionals, especially pharmacists and patients.

Differential Patterns of Referral to Neurosurgery: A Comparison of Allopathic Physicians, Osteopathic Physicians, Nurse Practitioners, Physician Assistants, and Chiropractors

Rising cost and limited resources remain major challenges to U.S. health care and neurosurgery in particular. To ensure an efficient and cost-effective health care system, it is important that referrals to neurosurgery clinics are appropriate, and that referred patients have a reasonably high probability of requiring surgical intervention or, at a minimum, ongoing neurosurgical follow-up. This retrospective study tests the null hypothesis that the probability of a referred patient requiring surgery is independent of referring provider credentials and referring service specialty. A database of all patients referred to the neurosurgery clinic from 2015 through 2018 (n= 5677) was reviewed; the database included referring provider, referring provider specialty, number of subsequent clinic visits, and outcome of surgery or no surgery. Associations between categorical variables were tested using a χ2 analysis with post hoc relative risk (RR) calculations and binary logistical regression. Compared with patients referred by allopathic physicians, patients referred by osteopathic physicians (RR, 0.63; 95% confidence interval [CI], 0.48-0.84) and those referred by nurse practitioners (RR, 0.66; 95% CI, 0.51-0.86) were significantly less likely to require surgery. Probability of surgical intervention also varied by referrer specialty. Patients referred by neurologists required surgery 35% of the time, whereas patients referred by family practitioners required surgery 19% of the time, and patients referred by pediatricians required surgery only 7% of the time (P<0.01). Binary logistic regression revealed that referrals from nurse practitioners and osteopathic physicians were independently associated with a decreased probability of surgical intervention. Our data strengthen the concept of having interdisciplinary teams led by physicians at the primary care level to ensure appropriate referrals. Training and adherence to guidelines must continually be reinforced to ensure proper referrals.

Complex care and contradictions of choice in the safety net.

This article explores the complicated and often-contradictory notions of choice at play in complex care management (CCM) programmes in the US healthcare safety net. Drawing from longitudinal data collected over two years of ethnographic fieldwork at urban safety-net clinics, our study examines the CCM goal of transforming frequent emergency department (ED) utilisers into 'active' patients who will reduce their service utilisation and thereby contribute to a more rational, cost-effective healthcare system. By considering our data alongside philosopher Annemarie Mol's (2008) conceptualisation of the competing logics of choice and care, we argue that these premises often undermine CCM teams' efforts to support patients and provide the care they need - not only to prevent medical crises, but to overcome socio-economic barriers as well. We assert that while safety-net CCM programmes are held accountable for the degree to which their patients successfully transform into self-managing, cost-effective actors, much of the care CCM staff provide in fact involves attempts to intervene on structural obstacles that impinge on patient choice. CCM programmes thus struggle between an economic imperative to get patients to make better health choices and a moral imperative to provide care in the face of systemic societal neglect. (A virtual abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA).

Relationship preferences and experience of primary care patients in continuity of care: a case study in Beijing, China

BackgroundContinuity of care can bring a wide range of benefits to consumers, providers and health care systems. This study aimed to understand the relationship preferences of primary care patients and their associations with patient experience of continuity of care.MethodsA questionnaire survey was conducted on 700 patients who sought medical care from a community health organisation in Beijing. The survey contained four items examining the relationship preferences of the respondents, and a modified Questionnaire of Continuity between Care Levels (CCAENA) measuring patient experience of continuity of care based on a three dimensional (relational, informational and managerial) model. The associations between the relationship preferences and the experience of respondents in continuity of care was tested using a linear regression model controlling for age, sex, education, medical insurance, personal income and servicing facilities.ResultsThe respondents experienced relatively lower levels of informational and managerial continuity compared with relational continuity of care. More than 80% of respondents preferred free choice and a continuing relationship with doctors, compared with 59% who endorsed community facility control over hospital appointments. A preference for a continuing relationship with doctors was associated with all aspects of continuity of care. A preference in favour of community facility control over hospital appointments was a strong predictor of managerial continuity (β = 0.333, p < 0.001) and informational continuity (β = 0.256, p < 0.001). Patient preference for free choice of doctors was positively associated with relational continuity with specialists (p < 0.001), but not with primary care providers (p > 0.08). Perceived importance of information exchange was associated with relational and managerial continuity (p < 0.05), but not with informational continuity (p = 0.34).ConclusionsPatients prefer a high level of freedom of choice and sustained individual relationship with doctors. Relationship preferences of patients are associated with their experience of continuity of care. But patient strong preference for free choice of doctors is not aligned with relational continuity with primary care, a desirable feature of cost-effective healthcare systems.

The impact of radiotherapy costs on clinical outcomes in breast cancer

Background and purposeIn cost-effective healthcare systems, the cost of services should parallel patient complexity or quality of care. The purpose of this study was to determine whether the cost of radiotherapy correlates with patient-related outcomes among a large cohort of breast cancer patients treated with adjuvant breast radiation. Materials and methods23,127 women with non-metastatic breast cancer undergoing radiotherapy after breast conservation surgery were identified from the Surveillance, Epidemiology, and End Results database from 2000 to 2009. Medicare reimbursements were used as a proxy for cost of radiotherapy, and Medicare claims were examined to identify local toxicities, and breast cancer-related endpoints. The impact of cost on these outcomes was studied with multivariable Fine-Gray models to account for competing risks. ResultsThe median cost (and interquartile range) of a course of breast radiation was $8100 ($6700–9700). Increased radiation costs were not associated with the occurrence of treatment-related toxicities (all p-values>0.05), ipsilateral breast recurrence (p=0.55), or breast cancer-related mortality (p=0.55). ConclusionHigher costs for adjuvant radiation in breast cancer were not associated with a decreased risk of patient-related outcomes suggesting inefficiency in Medicare reimbursements. Future efforts should focus on prospective evaluation of alternative payment models for radiotherapy.

Quality improvement in general practice

Quality improvement describes the process of improving patients’ safety, experiences and health outcomes by systematically addressing individual and organisational processes. This is aimed at creating a ‘self-improving NHS’, in which individual clinicians are empowered to make changes toward a more efficient, safe and cost-effective healthcare system that is readily able to respond to patients’ needs. Improvement science is increasingly recognised as a central component to healthcare, and with general practice taking on added responsibility for the healthcare budget, it is essential that our training addresses aspects of healthcare organisation and improvements. This article offers a summary for AITs and GPs to further their understanding of improvement science. It provides some useful methods to facilitate the delivery of change in the GP surgery.

WSN4QoL: A WSN-Oriented Healthcare System Architecture

People worldwide are getting older and this fact has pushed the need for designing new, more pervasive, and possibly cost effective healthcare systems. In this field, distributed and networked embedded systems, such as wireless sensor networks (WSNs), are the most appealing technology to achieve continuous monitoring of aged people for their own safety, without affecting their daily activities. This paper proposes recent advancements in this field by introducing WSN4QoL, a Marie Curie project which involves academic and industrial partners from three EU countries. The project aims to propose new WSN-based technologies to meet the specific requirements of pervasive healthcare applications. In particular, in this paper, the system architecture is presented to cope with the challenges imposed by the specific application scenario. This includes a network coding (NC) mechanism and a distributed localization solution that have been implemented on WSN testbeds to achieve efficiency in the communications and to enable indoor people tracking. Preliminary results in a real environment show good system performance that meet our expectations.

After-hours coverage of cardiothoracic critical care units by non-surgeons: process and value issues

One article [1] and three commentaries in the January 2013 issue of the Journal discuss the coverage of cardiothoracic surgery (CTS) intensive care units by non-surgeons. Motivations for the paper by Skinner et al are: an increasing pressure to reduce the cost; a shortage of junior CTS surgeons and decreased interest in CTS critical care. The study’s stated objective is to ‘reduce staffing cost’, based on assumptions that non-surgeons can replace surgeons in the same job, for ‘significantly’ less money, with ‘somewhat equal’ results and ‘acceptable losses’; because ‘it is not rocket science’. While cost-cutting is often the ‘easy way out’ to increase value in healthcare, the more demanding task of increasing quality by improving safety, effectiveness, appropriateness, equitability and accessibility is what truly and reliably leads to an enduring, costeffective health-care system, on a local or national scale [2]. Deficiencies in the broad-based education, abbreviated clinical training and limited skill sets of non-surgeons seriously impair their situational/environmental awareness and processing of information, their decision-making process and the implementation of decisions, as in the proposed ‘emergent resternotomy in the ICU’ protocol—an often challenging situation for experienced CTS surgeons. Therefore, non-surgeons are not properly qualified to be the primary decision-maker in the high-risk environment of cardiothoracic surgical critical care (CTSCC). Moreover, ‘telephone management’ causes delay in information processing and increases the risk of errors [3]. A flight attendant safely landing a commercial airliner based on remote instructions happens only in a Hollywood film (http://www.imdb.com/title/tt0071110/). Ethically, patients treated by surgeons during ‘normal business hours’ while by non-surgeons in the ‘after-hours’ raises serious issues of trust between the patient and the physician, upon which rapport, agreement and consent are based. Patients can have the impression of being ‘abandoned’ by the physician and their care delegated to a ‘professionally inferior’ or a ‘less qualified’ practitioner. Professionally, professional governing organizations (such as specialty boards) have their mission as the only authorities regulating the specific education, training, proficiency requirements, examination, certification, licensure, scope of practice, duties, responsibilities and expectations, accountability and disciplinary action for all practitioners in any clinical field [4, 5]. The solution for staffing issues in clinical environment should be based on sound scientific principles that take into account the projected clinical needs in the community; the expected output from medical and allied health schools and training programmes; established, evidence-based standards of care and the appropriate education, training, skill sets, certification and credentialing of specific classes of clinicians. The shortage in surgeons cannot be remedied by drawing from another pool of clinicians that is also severely limited in number and suffers from the same ‘brain drain’. Measures to address the persistent shortage of surgeons and applicants to surgical programmes should be based on providing more incentives for medical school graduates to choose specific areas of practice as career goals. Changes to the work hours and shifts may also be beneficial in this regard. These decisions, which impact on professional standards and practice, should be made by the relevant clinical professionals, and never left to administrators or politicians.

Comparative Effectiveness Research in the Regulatory Setting

Consumers today have access to more information regarding everyday decisions than ever before. Healthcare is no exception. The US health reform laws signed in March 2010, provided a vehicle for systematically facilitating the application of this trend to the US healthcare system through the creation of an independent, government-funded institute, whose purpose is to advance the understanding of which treatments and approaches to healthcare work best for which patients. This article discusses the implications of comparative effectiveness research (CER) for governments, industry, healthcare systems, clinicians and patients. Properly developed and applied information derived from CER can help establish the value of medicines, procedures and services, and promote a more qualityfocused, cost-effective healthcare system. However, much uncertainty remains that centres on precisely how this information will be used. Recently, many patient groups, physicians and biopharmaceutical companies have raised concerns that CER might have the unintended consequences of restricting access to treatments. These effects must be weighed carefully when considering whether comparative effectiveness data should become a prerequisite for US FDA submissions. The process of designing and implementing comparative clinical trials at such an early stage in product development poses numerous challenges including dose selection, use of marketed comparators (which may lead to consumer bias and increased patient dropout rates), physician comfort and experience (for medical devices), and endpoint selection, among others, and could delay introduction of new therapies. In addition, ‘over-interpretation’ of early comparative data could lead to an underappreciation of benefits in patient subgroups and an undervaluation of incremental innovation. Thus, a requirement for premarketing comparative studies could prove not only to create a costly disincentive to invest in developing therapies, but could also have a detrimental impact on their development. Regardless of how information is provided to patients and healthcare decision-makers, it should be gathered in a manner that does not delay patient access to new technologies nor hamper innovation. The desire to provide consumers with more information regarding choice is well intentioned; however, patient care and satisfaction should always remain the foremost concern when discussing the implementation of new policies in the healthcare field.

Adoption of Electronic Health Care Records: Physician Heuristics and Hesitancy

Political, economic, and safety concerns have militated for the adoption of Electronic Health Records by physicians in the United States, but current rates of adoption have failed to penetrate the 50% level. A qualitative phenomenological study of practicing physicians reveals stumbling blocks to adoption. Maintaining a physician's perceived sense of control of the process is key. Electronic Health Records (EHRs) are critical to the support of research, quality control, cost reduction, and implementation of new technologies and methods in healthcare. Progress in the USA towards adoption of standardized EHRs has been halting. We discuss the results of a phenomenological study of physicians and draw conclusions that will assist all stakeholders in building a more consistent, comprehensive, and cost-effective healthcare system. When attempting to persuade physicians to migrate to an EMR-based solution, a strong focus on the control that physicians will have should be emphasized. The transition to an EHR system is eased by clearly articulating early in the process the potential benefits and the degree of control physicians can have in the use of the applications.

Fractured neck of femur: guidelines and beyond

Fractured neck of femur: guidelines and beyond

Continent-wide anaesthesia guideline

De Hert S, Imberger G, Carlisle J, et al. Preoperative latest evidence-based medical knowledge to simplify and/or eliminate unnecessary steps. Physicians are expected to be familiar with clinical guidelines, but should note that they are advisory in nature and are there to help with safer decision making, something which might vary according to the patient’s condition and the available resources. Practice guidelines should be revised periodically to accommodate newly published data. In 2007, the Anaesthesiology Board of European Union of Medical Specialists published guidelines for the safety and quality of anaesthesia. A more recent milestone was the Helsinki Declaration on Patient Safety in Anaesthesiology published in June 2010. This represented a European consensus on measures to improve patient care and it set out a framework for good practice. In order to constrain costs and standardise practice across Europe, the European Society of Anaesthesiologists (ESA) took a giant step forward by committing to the development of evidenced-based clinical guidelines and recommendations. In this issue, the unique specific task force, led by Professor Stefan De Hert, has published an outstanding guideline for the preoperative evaluation of adult patients undergoing elective non-cardiac surgery. Their recommendations are very comprehensive. They cover a wide range of topics that include cardiovascular disease, respiratory disease, obstructive sleep apnoea (OSA), renal disease, diabetes, obesity, coagulation disorders, anaemia, the elderly patient, alcohol addiction and allergy. They also cover concurrent medication, and preoperative testing. In addition, there is a very useful section on airway evaluation.

Paediatric radiology seen from Africa. Part II: recognising research advantages in a developing country

Radiologists in developing countries cite numerous reasons for poor research output including heavier workloads, poor remuneration (resulting in "brain drain"), poor infrastructure, language barriers, lack of modern imaging equipment, and a disease spectrum that may be of little interest to journals and readers in the developed world. On the other hand, large populations of patients suffering from distinctive diseases, cost-effective healthcare systems, and a set-up with highly centralised tertiary referral hospitals, may be seen as advantages to those willing to tap into this as a data source for research. The lack of resources may even stimulate cost-effective innovations relevant to the needs of poor communities. This paper challenges preconceived ideas and identifies advantages for radiologists in developing countries to producing good research and publications. It also cautions against "annexation of sites" by stakeholders from developed countries, and suggests simple solutions to maximise research output without a significant financial cost.

A framework for health care information assurance policy and compliance

Introduction As many as 400 people may have access to one's personal medical information throughout the typical care process. Disclosures of sensitive information such as emotional problems, sexually transmitted diseases, substance abuse, and genetic predispositions to diseases---could cause embarrassment and affect insurability, child custody cases, and employment. A recent survey by IDC found that "Most consumers …were uncomfortable with their health plan sharing health information with a hospital, a specialist or their primary care doctor… (and) were concerned with who saw their information and were worried that the information could be made available online… (and) other respondents said they didn't trust their health plan or hospital to protect their information." Clearly, patients (consumers) feel that it is critical that their medical information is held in confidence. If patients do not feel that their personal medical information will be kept confidential, they may withhold important medical information from health care providers making it difficult to provide quality and effective health care. This issue of safeguarding sensitive patient information has become even more critical given that the Electronic Protected Health Information (PHI), in Electronic Medical Records (EMR) as mandated by the Health Insurance Portability and Accountability Act (HIPAA), may consist of a patient's medical, demographic and insurance information. Thus, presenting a significant information assurance and security challenge to the health care industry as reflected by the consumers' concerns related to building trust with health care community. If the health care industry falls behind in assuring the public that it can indeed safeguard patient information, then the initiative to create a more efficient and cost effective health care system by using Information Technology will be in serious jeopardy. The research presented in this article addresses this important information assurance and security challenge by building upon past research and presenting a framework of Information Assurance and Compliance developed through multi-site case study approach involving multiple health care providers in the U.S. Mercuri correctly identified that "solutions (to the information assurance challenge) are not as simple as adding on security tools and providing employees with policies and procedures for their job classification and requiring them to read and sign off on them." Information Assurance (IA) technologies such as encryption, password protection, access control mechanisms, and so on, for PHI may not be sufficient, since not all individual health care professionals may be familiar with the requirements of the law nor sufficiently motivated or trained to protect private and sensitive patient information. Health care Information Assurance policy (IA Policy) may be in place due to HIPPA requirements, but if health care employees fail to comply with such policy then patient information will be at a risk for disclosure. In this context, Mercuri correctly underscores the importance of human and management factors related to compliance by stating that "…the workers (must be given) a sufficient period in which to incorporate the new structures and rules into their culture and ethics. Otherwise efforts (related to IA Policy compliance) may be frustrated and unsuccessful." Even though human and management factors, related to compliance, have been recognized as important as technical factors in providing security to PHI in the health care industry, there is a lack of well-developed framework to understand IA policy compliance factors addressing the behavioral dimension in the context of patient health care information. Without such a framework, it is difficult to develop both managerial interventions and research studies in this important area of health care information assurance. The purpose of this research (using multi-site case research approach) is to present such a research framework that examines what factors affect health care employee's behavior to comply with information assurance (IA) policy related to protection of patient health care information. We also present sample measures to assess individual compliance. In the light of recent breaches and/ or theft of sensitive consumer data from banking, academic institutions, government agencies, and health care providers, this study provides a framework that can be extended and adapted to understand IA Policy issues in health care as well as in other industries. Therefore, the implication of this study is much broader and can be extended to other industries with appropriate adaptation. The unifying foundation for our research framework is the Theory of Reasoned Action (TRA). TRA posits that external factors affect beliefs and beliefs in turn affect attitudes, and attitudes affect intention which ultimately affect one's behavior. We examine how these concepts are related to one's behavior in complying with information assurance policy regarding patient health information. Using TRA, we build our framework on solid theoretical foundations drawing from research in technology acceptance model, information assurance and security, ethical behavior, organizational culture4 and health information management.

Strong medicine: research, education, and patient care in general practice

The fact that strong general practice is an essential component of a high quality and cost-effective healthcare system is a message that has never been fully absorbed by successive ministries of health in the UK. (The over-worked and almost meaningless term ‘primary care led’ seems to have been used in the mistaken belief that it just meant cheap.) Ironically, it is a message that has been stated clearly in the US, where Barbara Starfield, the distinguished health services researcher at Johns Hopkins, has published high quality research to make the point1,2 and where Don Berwick, President of the Institute for Healthcare Improvement, wrote in his essay celebrating 60 years of the NHS that, ‘General practice is the jewel in the crown of the NHS. Save it. Build it’.3 We have done neither but instead, with the encouragement of the government, have half-dismantled it and sleep-walked into a time of peril for general practice and for patient care.4 Almost all of the core characteristics of general practice identified by Starfield are in danger of becoming eroded by successive and often poorly-informed lurches in health policy. General practice in the UK was never perfect — there was never an unalloyed golden age …