Cost-effective Health Care System Research Articles

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 …

Distributed Agent Based Interoperable Virtual EMR System for Healthcare System Integration

One of the major problems in health care system integration is the formidable cost of mediating between myriad vendors and policy makers for updating existing heterogeneous systems to support a great variety of standards or interfaces. To provide cost-effective healthcare system integration solution, this paper presents a Graphical User Interface state model (GUISM) for automatically exchanging information with existing healthcare software through their GUIs with no modifications needed to them. This can save the huge cost of upgrading, testing and redeploying the existing systems. By using the GUISM model, distributed agents are deployed to the client computers interacting with the local electronic medical system (EMR) for communicating with other EMR systems. The whole system is called virtual EMR system and each client in this system can request needed patient healthcare information without knowing the actual location of the data.

Revisiting the Value of Nursing Care

When I attended the 2008 Fall Summit of The Nursing Organizations Alliance (NOA) in Albuquerque, New Mexico, the American Nurses Association President, Rebecca M. Patton, shared with the attendees an idea that had come out of the American Nurses Association’s meeting with its 24 Organizational and Work Force Advocacy Affiliates. What was suggested was for each President to use their ‘‘column’’ in May/June of 2009 to speak to the value of nursing. With a new White House Administration that’s put health care near the top of the nation’s agenda, registered nurses now have an incredible opportunity to help shape a safe, quality, and cost-effective health care system. It is essential to know and recognize the value of nursing that society, governments, and the profession itself have of nursing as a profession in terms of why it exists and how it functions. ‘‘Value’’ means the perceived worth, importance of estimation of nursing as an occupation in the eyes of various groups, including nurses themselves. Individual values in the work place are shaped by the position and responsibilities held. The most influential factors are integrity, respect, customer focus, involvement, quality, creativity/innovation, accountability, and fairness (Buffron, Sullivan, & Sullivan, 2002). The Strategic Plan for ARIN does reflect upon the value of nursing care. Our core purpose or reason for being is to foster the growth of nurses who advance the standard of care in the imaging environment. The public may not think about the solid educational background of registered nurses or the fact that we are bound by a Code of Ethics, or that we develop and follow standards of care. But they know that we are the ones who respond when they’re in pain or are afraid, answer their call lights 24-7, and take the time to listen

Universal health care, genomic medicine and Thailand: investing in today and tomorrow

One potential outcome of investing in genomic medicine is the provision of tools for creating a more cost-effective health-care system. Partly with this aim in mind, Thailand has launched two genotyping initiatives: the Thai SNP Discovery Project and the Thai Centre for Excellence in Life Sciences Pharmacogenomics Project. Together, these projects will help Thailand understand the genomic diversity of its population and explore the role that this diversity has in drug response and disease susceptibility in its population. A major future challenge will be for Thailand to integrate genomic medicine in its relatively young universal health-care system.

Can health care financing policy be emulated? The Singaporean medical savings accounts model and its Shanghai replica

Each nation's government is searching for a cost-effective health care system. Some nations are developing their health care financing methods through gradual evolution of the existing ones, and others are trying to adopt other nations' successful schemes as their own financing strategies. The Singaporean government seems able to finance its nation's health care with a very low gross domestic product (GDP) input. Since the implementation of the medical savings accounts schemes (MSAs) in 1984, Singaporean government's share of the nation's total health care expenditure dropped from about 50% to 20%. Inspired by Singapore's success, the Chinese government adopted the Singaporean MSAs model as its health care financing schemes for urban areas. Shanghai was the first large urban centre to implement the MSAs in China. Through the study of the Singapore and Shanghai experiences, this article examines whether it is rational to borrow another nation's health care financing model, especially when the two societies have very different socioeconomic characteristics. However, the MSAs' success in Singapore did not guarantee its Shanghai success, because health care systems do not work alone. Through study of the MSAs' experiences in Singapore and Shanghai, this paper examines whether it is rational to borrow another nation's health care financing model, especially when the two societies have very different socioeconomic characteristics.

Quality assessment of pacemaker implantations in Denmark.

Quality assessment of therapeutic procedures is essential to insure a cost-effective health care system. Pacemaker implantation is a common procedure with more than 500,000 implantations world-wide per year, but the general complication rate is not well described. We studied procedure related complications for all implantations performed in an entire nation over a 3-year period. A prospective study of complications related to 99% of the 5648 primary pacemaker implantations performed in the 12 Danish pacemaker centres in 1997-1999 was carried out. Overall 76% of the patients received a physiological pacemaker system and 91% received the optimal pacing mode according to international guidelines. Perioperative complications requiring reoperation were: haematoma 0.3%, atrial lead related 1.9%, ventricular lead related 1.7%. Late complications requiring reoperation were: infection 02%, atrial lead related 13%, ventricular lead related 1.2%. The complication rate decreased over the study period, but overall the complication rate was higher than expected and showed considerable variation between centres. Our results demonstrate that sensitive data such as complications related to pacemaker implantations can be collected on a national basis. We suggest that a reoperation rate higher than 3% for atrial as well as ventricular pacing electrodes in the individual implanting centre should cause the centre to evaluate carefully the procedure as well as the performance of the individual implanter.

AHSCs: more important than ever in the century of health research.

We are in the midst ofa profound revolution in health research, a revolution being driven by our emerging understanding of the molecular basis of life and human disease. This revolution is creating a century of health research, characterized by the convergence of virtually all disciplines, from mathematics to the social sciences and humanities. This convergence of disciplines is introducing radical changes and opportunities in the discovery and R&D process of health research. Academic health sciences centres (AHSCs) are strategically placed to contribute to, and benefit from, this revolution. To that end AHSCs require exceptional visionary leadership, a commitment to clinical and research excellence, a full appreciation of the complete tripartite mission of AHSCs, and the development of an outward-looking stance that includes the development of public policy. The federal governments clear and sustained commitment to health research, as demonstrated recently by the 15% increase to the Canadian Institutes of Health Research budget, provides an important opportunity for AHSCs to demonstrate their crucial role in both the development of an innovative and cost-effective healthcare system and to Canada's broader social and economic agenda.

Authors' Response to Commentary

HE aging of the world's population due to (a) an increasing absolute number of elderly people and (b) an increased expectancy is well established (1). However, in what way pro­ portional healthy expectancy or perhaps, in other words, satisfactory quality of elderly life can be achieved, is still an important topic of multiple research. Because sensory proper­ ties of food are almost exclusive factors that remain important until the very last end (2), it is of great value to investigate the decline in taste and smell perception and its impact on food en­ joyment and total food intake. In her comment, Schiffman ad­ vocates a greater understanding of the impact of especially dif­ ferent types of taste and smell dysfunction on appetite in relation to developing and providing cost-effective health care systems for the elderly population. Different types of chemo­ sensory losses may have divergent effects on food intake and nutritional and health status. Schiffman argues that poor appetite is one cause of decreased energy intake. Consequently, effects on macro- and micronutri­ ent status, clinical nutritional parameters, and finally overall functioning are induced. We fully agree that this may be espe­ cially the case in critically ill patients and perhaps frail elders, who accordingly have a high risk of developing deficiencies. We, however, could not confirm this premise in our study (3). We were able to demonstrate a firm relationship between sen­ sory perception and appetite, but low scores on the appetite questionnaire were not significantly related to low dietary in­ take, adverse quality of dietary intake, or low body mass index (BMI) in our elderly population. A possible explanation may be that institutionalized elders eat because they understand that they simply have to eat. Another reason may be that they do not have to prepare the hot meal themselves anymore. If the hot meal is served, they may eat it because this older generation will not throw food away. Free-living elders with a poor appetite may be reluctant to prepare something regularly. It may just be too big an effort to overcome, and when there is no control by a central kitchen or staff, they may end up with only a sandwich. To our knowledge, there is no available uniform, validated approach of measuring appetite and feelings of hunger. The questionnaire developed for our study was the first attempt to expand the concept of appetite in a direction that is more than one question only. The internal validity was satisfactory, but still a lot of work has to be done with respect to the external va­ lidity. In our department, we are currently trying to validate the questionnaire with objective measures such as hormone levels, as leptine or cholecystokinine. In an earlier study by Schiffman and Warwick (4) it was ob­ served that flavor enhancement could improve palatability and intake. We, likewise, attempted to increase pleasantness and inB334 take of foods for elders by increasing sucrose concentrations in breakfast items in a trial published in 1996 (5). The preferred concentration of sucrose in these foods was determined initially in our laboratory. We were unfortunately not able to reproduce the results that were found by Schiffman. No increase in pleas­ antness occurred, whereas the increase in energy intake was at­ tributable to the increase of sucrose concentration. One of the explanations may be that results obtained from lab studies do not necessarily predict behavior in the free-living situation. From this point of view, it can be argued that more research should be done in elders' actual living situations, and taste­ and-spit methods should be left to the laboratory. Perhaps, as has been hypothesized by Schiffman, different types of chemosensory losses provoke different effects on food intake. In this light the results of Duffy and colleagues (6), that olfactory dysfunction correlates with a higher intake of fats and sweets, should be interpreted. The increased preference for sweeter, saltier, and fatter foods may indeed interfere with the current diet recommendations for elderly people and may influ­ ence the occurence of chronic diseases. The intake of high- fat foods, together with reduced physical activity and disuse of muscles, may induce adverse changes in body composition. On the other hand, in the very old in contrast to the younger old, a further decline in activity pattern and energy expenditure may consequently hamper appetite and total dietary intake. This, in tum, may cause (micro)nutrient deficiencies. It is assumed that this can happen not only to ill patients but also to a group of el­ ders who may be referred to as ''frail'' or at risk.

Reviving Primary Care: A US-UK Comparison

Health Systems This book deserves your consideration because of its important message. Whether you need to read it depends on how much you already know about the topic, how tolerant you can be of the book's idiosyncrasies, and your underlying values. The central message is that the United States spends far too much on medical care, given what other countries spend and what our outcomes appear to be. The solution proposed by the authors is to strengthen primary care, which will lead to a more cost-effective health care system. There is little question that the United States spends more on medical care as documented by these authors and many who preceded them. Whether we spend too much given the outcomes is a much more complicated issue. The book's focus is on a comparison of the United Kingdom (UK) and US health care systems, emphasizing their approaches to primary care. The

The challenge of changing healthcare systems.

Healthcare systems are in flux throughout the world. Traditional structures and attitudes are changing. The balance of power between political bodies, payers, providers and patients is being destabilised. New approaches by governments and forward integration by drug companies and payers into care management are all major changes from the past. In the future, healthcare providers, particularly hospitals, will have to complement medical with business skills to survive in a more competitive environment. Experience shows that there is major potential for improvement in terms of radical rethinking of how care is provided (e.g. at least a 30% reduction in hospital days per insured life together with quality-of-care improvements). In particular, the economic value of changes in treatment (e.g. ambulatory surgery, switch to home therapy) should be understood and optimised. In a new world scenario, payers and providers will shape the healthcare environment by introducing novel approaches and integrating healthcare delivery. This process, coupled with the introduction of new approaches to competition and risk sharing by the government, could cause the emergency of high performance and more cost-effective healthcare systems.

Problems with employer-provided health insurance--the Employee Retirement Income Security Act and health care reform.

Health care reform is in the wind. As the nation prepares for a new presidential term, a more equitable and cost-effective health care system is beginning to sound inevitable.1 But the shape of tha...

The key role of health insurance in a cost-effective health care system Towards regulated competition in the Dutch medical market

The previous two sessions of this Symposium have dealt with incentives for cost-effective provider behaviour. Although incentive-reimbursement, which rewards the providers for delivering medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not sufficient. As long as the insured consumers have both comprehensive health insurance coverage and freedom of choice of provider, providers will have great difficulty in resisting consumers' demand for ever more costly medical care, and politicians or other decision-makers will have great difficulty in restricting capacity and in preventing overcapacity. Fear of losing patients or voters might dominate. Therefore, in this session we shall focus on the key role of health insurance in a cost-effective health care system and on consumer incentives and insurer behaviour. If the consumers have a choice between several health plans such that the premiums or the out-of-pocket payments reflect the cost-effectiveness of the provider chosen, this will give the provider incentives for cost-effective behaviour. As a result, competition may arise between different providers, between provider-groups, and between provider-insurer organizations. Although market forces do play an important role in a competitive health-care system, competition should not be confused with a “free market”. Besides financial arrangements to protect the poor, procompetitive regulation is needed to guarantee a “fair competition”.