Effectiveness Of Health Care Delivery Research Articles

A comparison of knowledge of medical students and practicing primary care physicians about cardiovascular risk assessment and intervention

Background. Heart attack and stroke are still prevalent causes of death and disability in the U.S. adult population (1, 2). Studies (3–9) have shown that modification of hypertension, smoking, and hypercholesterolemia can reduce risks for atherosclerosis and subsequent cardiovascular events. Therefore, it is important that physicians be skilled in assessing and modifying patients' overall cardiovascular risk. This study compares acquired knowledge of second-year medical students about cardiovascular risk assessment with knowledge in a selected group of practicing primary care physicians, who are members of the medical school's clinical faculty, using a new experimental testing technique called the tailored response test (TRT). Methods. Students performed a structured cardiovascular risk intervention on a patient in primary care clinics. Their acquired knowledge was then tested using the TRT, which contained 43 discrete judgments about a clinical case. Test scores of students and faculty were compared. Results. Both students and faculty demonstrated knowledge about the most important risk factors, appropriate screening tools, and interventions. However, the selected physicians did not demonstrate knowledge of certain important risk assessment and intervention recommendations, based on national standards. Only 38% of faculty and 27% of students were aware that a “fasting” serum cholesterol is not needed for screening, 30% of faculty believed that if cholesterol was over 300 they would “probably prescribe medicine” before other intervention strategies were tried, and 32% of faculty and 30% of students would order a screening chest X-ray, which is incorrect in the case history. Conclusions. The TRT, in contrast to self-report surveys, demonstrates that important cardiovascular risk assessment and intervention knowledge, with implications for cost effectiveness in health care delivery, has not penetrated to a selected group of physicians who are members of the medical school's clinical faculty and therefore serve as role models for medical students. This is disturbing, in light of current emphases on cost effectiveness in health care. Greater undergraduate curricula and CME emphasis on cardiovascular preventive practice is needed, such that almost 100% of students and faculty demonstrate knowledge, and practice, of preventive medicine according to national standards. In turn, groups developing national standards are enjoined to design and implement effective approaches for disseminating these recommendations.

Hospital design and the temporal and spatial organization of nursing activity

Abstract The effectiveness of health care delivery in hospitals is determined, in part, by the design of the physical environment and by the spatial organization of work. This paper presents an analysis of the spatial and temporal organization of the work of nurses in the medical and surgical units of French hospitals. In both cases the units were designed around a ‘U’ shaped configuration. The data from these analyses focused on the number of trips undertaken by nurses in completing the various aspects of their work. The results, it is argued, are useful towards the redesign of the units.

Economic Evaluation of Effectiveness in Health Care Delivery

This work focusses on two major aspects of public decision-making and policy analysis. First, to present a set-up for multi-criteria decision analysis (under certainty) based on interactive soul searching between the decision maker and the decision analyst (consultant) in which the decision maker repeatedly reveals his value judgement on a number of conflicting objectives and organizes his choice process in an adaptive fashion.Second, to show the usefulness of this kind of approach for practical decision-making and resource planning. Multi-criteria decision analysis has found applications in diverse fields, related to public policy decisions. But this work is probably the first comprehensive attempt to apply multi-criteria decision analysis to the choice of modes of health care delivery as a public decision problem.

CHANGING HEALTH CARE DELIVERY THROUGH A PROSPECTIVE/ INCENTIVE REIMBURSEMENT SYSTEM.

This paper describes a prospective/incentive reimbursement system designed to increase the efficiency and effectiveness of health care delivery. The system calls for rate review where reimbursements are related to planned expenditures. Hospitals are placed at risk for the excess of actual expenditures over actual reimbursements, while being allowed to earn as an incentive a portion of the excess of actual reimbursements over actual expenditures. The amount of incentive funds earned by hospitals is a function of the desirability of the use to which the hospitals will put those funds. In support of the motivational aspects of the system, technical assistance is provided to hospitals in budgeting, capital expenditure planning and management engineering.

Small area variations in health care delivery.

Health information about total populations is a prerequisite for sound decision-making and planning in the health care field. Experience with a population-based health data system in Vermont reveals that there are wide variations in resource input, utilization of services, and expenditures among neighboring communities. Results show prima facie inequalities in the input of resources that are associated with income transfer from areas of lower expenditure to areas of higher expenditure. Variations in utilization indicate that there is considerable uncertainty about the effectiveness of different levels of aggregate, as well as specific kinds of, health services. Informed choices in the public regulation of the health care sector require knowledge of the relation between medical care systems and the population groups being served, and they should take into account the effect of regulation on equality and effectiveness. When population-based data on small areas are available, decisions to expand hospitals, currently based on institutional pressures, can take into account a community's regional ranking in regard to bed input and utilization rates. Proposals by hospitals for unit price increases and the regulation of the actuarial rate of insurance programs can be evaluated in terms of per capita expenditures and income transfer between geographically defined populations. The PSRO's can evaluate the wide variations in level of services among residents of different communities. Coordinated exercise of the authority vested in these regulatory programs may lead to explicit strategies to deal directly with inequality and uncertainty concerning the effectiveness of health care delivery. Population-based health information systems, because they can provide information on the performance of health care systems and regulatory agencies, are an important step in the development of rational public policy for health.