Health System Programs Research Articles

Results of a Web-based Patient Education Program in a Multi-Center University Health System

Results of a Web-based Patient Education Program in a Multi-Center University Health System

Contradictions of public health policies geared to rare disorders: the example of the Osteogenesis Imperfecta Treatment Program in the Brazilian Unified Health System (SUS)

The scope of this paper is to examine the process of consolidation of a public health policy in Brazil geared to a rare disorder, namely osteogenesis imperfecta, the treatment for which has fallen under the responsibility of the Brazilian Unified Health System (SUS) after the publication of Ministerial Ruling GM/MS2305/2001. The implementation of this law has been accompanied by many contradictions, especially with respect to therapeutic decisions and the strengthening of the specialized network for addressing this condition. These attitudes are clearly shown both by the drafting process and the final text of the new law (Ministerial Ruling 714/2010).

News from the NIH: research to evaluate “natural experiments” related to obesity and diabetes

Obesity is a major contributor to many serious health conditions that increase morbidity and reduce quality of life. For example, obesity is a significant risk factor for diabetes, cardiovascular disease, and certain forms of cancer. The prevalence of obesity in children and adults in the USA has dramatically increased in the past four decades [1, 2]. Although some cities and states are showing reductions in rates of childhood obesity, the prevalence is still far above 1970 levels [3–5]. Diabetes currently affects an estimated 25.8 million people in the USA and another 79 million Americans are estimated to be at greatly increased risk of developing diabetes in the next several years [6]. Further, most adults with diabetes in the USA are not meeting the recommended goals for diabetes care [7]. Overweight, obesity, and/or excessive weight gain during pregnancy are also contributing to rising rates of gestational diabetes mellitus which in turn increases risk of future type 2 diabetes in the mother and child. In addition to the considerable impairments to health and quality of life with these conditions, there are also serious economic consequences. The estimated current annual cost of diabetes alone in the USA is $245 billion dollars per year with $176 billion in direct medical costs and the remainder related to reduced productivity [8]. The increasing challenges of obesity and its related health conditions in our society also coincide with a dynamic time for health care in the USA, including changing consumer demands (employers and individuals) and the pressing need to deliver evidence-based care, improve health outcomes for all Americans, and control costs. In communities and in health-care settings, many of the policy and programmatic changes are evidence-informed, but often little is known about population-level effects. Rigorous scientific evaluation of these “natural experiments” can help to more rapidly build an evidence base to inform key stakeholders and policy makers. Evaluation research generally, and rigorous evaluation of natural experiments specifically, is increasingly recognized as an important and appropriate approach to health-related research, particularly in the context of policy and environmental [9, 10] change. The term experiment in natural experiments is something of a misnomer as the implementation of these public health and health-care system policies and programs are not often designed as true experiments. Generally, the term natural experiment refers to an exposure or change that is not directly manipulated by the researcher, but rather the result of policy or program interventions that are varied in their implementation along a number of possible dimensions, such as time, geography, or content. Research that evaluates the real-world implementation of polices and program has some challenges such as the potential for bias, confounding, and threats to casual inference. Despite these limitations, the data from natural experiment research offers unique opportunities to enrich the evidence base and can offer advantages not provided by other research designs, such as improved external validity. This research can provide important data about the impact of a policy or program in real-world settings and populations; see for example the well-known study on the impact of education on health outcomes by Lleras-Muney [11]. Often, these are data that would be very difficult, potentially unethical, and often cost prohibitive to collect in the context of an investigator-initiated randomized experiment [12]. Natural experiment research also allows for the assessment of potential unintended consequences or subgroup differences in response to the program or policy and measurement of implementation fidelity, variability, and process. Since 2010, several institutes and centers (ICs) at the National Institutes of Health have jointly issued funding opportunity announcements intended to support rigorous evaluation of natural experiments related to obesity and/or diabetes outcomes, including the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); National Cancer Institute (NCI); Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD); National Heart, Lung, and Blood Institute (NHLBI); National Institute on Aging (NIA); and the Office of Behavioral and Social Sciences Research (OBSSR). In these funding opportunity announcements, policies are broadly defined to include public policies at local, state, and federal levels of government and organizational level policies, such as those implemented by large organizations, worksites, or school districts. Polices can be formal such as laws and regulations or informal such as guidelines and procedures. Program is defined as a set of activities initiated by governmental or other organizational bodies to enhance obesity prevention and control.

Su sveikata susijusios gyvenimo kokybės samprata, stebėsenos ir vertinimo metodai bei reikšmė sveikatos politikoje

The aim of the study is to analyze the concept of health-related quality of life, its monitoring and evaluation methods and implications in health policy.The methods of the study include systematic review and comparative analysis of the data from Lithuanian and abroad scientific sources, legal documents, statistical databases, sociological research; data synthesis and generalization.Results and conclusions. The concept of health-related quality of life has certain points in common with the concept of health and quality of life concept, but researchers do not provide a uniform definition. Health-related quality of life research is applied not only to the medical clinical investigation of patients’ health-related quality of life, but also to the public health condition monitoring. The main research methods include special questionnaires, national and international public health and living conditions survey and statistical data of population health. Objective and subjective indicators of health-related quality of life are an integral part of the general quality of life indicators at both national and international levels. Information about health-related quality of life indicators are relevant to the assessment of health risks, social determinants of health, effectiveness of health system, health promotion and prevention programs, identifying priority for health and public policy.

Editorial introductions

Editorial introductions

Leveraging the strengths of an academic health system to improve community cancer care.

218 Background: To improve community cancer care quality, UC Davis Health System formed the UC Davis Cancer Care Network (CCN) to partner with select cancer centers in California to offer leading-edge care close to home. Hospital-based community cancer centers become affiliates of the UC Davis CCN through an evaluation process led by UC Davis. By synergizing the strengths of an academic health system and community-based oncology care, the network formalizes the commitment to collaboration with community providers. Methods: This quality model relies on a central university-based team interacting with affiliate sites to support them in their local missions. Affiliates progress through three phases of development of their cancer program. Each phase adds layers of quality to the organization. CCN staff members coordinate the phases: 1) Review and Develop Operations—site specific structures needed to be a comprehensive community cancer center; 2) Make Connections—within the network and the local community; 3) Become Self-Directed—identifying own needs and direction. The partnership attributes include: joint marketing, system synergies, certification assistance, coordinated service line development, dedicated personnel resources, on-site educational opportunities, and quality oversight. Results: Performance measurement includes: local market share, ACOS accreditation, adherence to national quality and patient satisfaction standards, assessment of community health needs and benefits, and enhancement of local capabilities (inpatient oncology unit, radiation, pathology, radiology, and surgical oncology services). Conclusions: This model demonstrates the benefit of partnering the strengths of an academic health system and community cancer programs to provide quality care.

Honouring choices Minnesota: scaling advance care planning to a diverse metropolitan population

Methods and benefits of ACP for geographic populations in the U. S. have been limited to relatively small populations such as La Crosse, WI (POP. 110,000). Beginning in 2008, the...

A comparison of policy and direct practice stakeholder perceptions of factors affecting evidence-based practice implementation using concept mapping

BackgroundThe goal of this study was to assess potential differences between administrators/policymakers and those involved in direct practice regarding factors believed to be barriers or facilitating factors to evidence-based practice (EBP) implementation in a large public mental health service system in the United States.MethodsParticipants included mental health system county officials, agency directors, program managers, clinical staff, administrative staff, and consumers. As part of concept mapping procedures, brainstorming groups were conducted with each target group to identify specific factors believed to be barriers or facilitating factors to EBP implementation in a large public mental health system. Statements were sorted by similarity and rated by each participant in regard to their perceived importance and changeability. Multidimensional scaling, cluster analysis, descriptive statistics and t-tests were used to analyze the data.ResultsA total of 105 statements were distilled into 14 clusters using concept-mapping procedures. Perceptions of importance of factors affecting EBP implementation varied between the two groups, with those involved in direct practice assigning significantly higher ratings to the importance of Clinical Perceptions and the impact of EBP implementation on clinical practice. Consistent with previous studies, financial concerns (costs, funding) were rated among the most important and least likely to change by both groups.ConclusionsEBP implementation is a complex process, and different stakeholders may hold different opinions regarding the relative importance of the impact of EBP implementation. Implementation efforts must include input from stakeholders at multiple levels to bring divergent and convergent perspectives to light.

How has the OSD affected our state hospitals

We look at the OSD process, and identify the potential impact of its deficiencies, on the state health system and teaching programs. Furthermore we look at the bargaining process available to state doctors, and suggest ways that this could be improved.

Efficacy of the Berkshire Health System Cardiovascular Health Risk Reduction Program

To assess the effectiveness of the Berkshire Health System Cardiovascular Health Risk Reduction Program. A within-group study design was conducted. Analyses were based on 502 employees who completed an initial and follow-up personal health risk assessment. One-on-one nurse coaching occurred, with referrals and recommendations based on screening results. Clinically and statistically significant improvements occurred between initial and second screenings for individuals with high systolic blood pressure, high diastolic blood pressure, high total cholesterol, low high-density lipoprotein, high low-density lipoprotein, and high glucose. Decrease in body mass index for obese individuals was marginally insignificant. Improvements were also observed in exercise, pleasure doing things, and mental health. Improvement in mental health occurred primarily in women and among those aged <50 years. The Berkshire Health System Program significantly improves cardiovascular health.

Experts Analyze Real Meaning of CATIE Study Findings

Experts Analyze Real Meaning of CATIE Study Findings

National Training Program for Comprehensive Community Physicians, Venezuela

Introduction Through the 1990s, wide disparities in health status were recorded in Venezuela, a mirror of poor social conditions, decreasing investment in the public health sector and a health workforce distribution unable to meet population health needs or to staff effective, accessible public health services. Venezuelans' health status deteriorated as a result. In 2003-2004, the Venezuelan government launched Barrio Adentro, a new national public health model aimed at assuring primary health care coverage for the entire population of an estimated 26 million. Cuban physicians staff Barrio Adentro clinics, mainly in poor neighborhoods, until enough Venezuelan physicians can be trained to fill the posts. Intervention Cuban experience with community-oriented medical education and global health cooperation was drawn upon to develop curriculum and provide faculty for the new National Training Program for Comprehensive Community Physicians, begun in 2005 in cooperation with six Venezuelan universities. The program differs from previous Venezuelan medical education models by adopting a stated goal of training physicians for public service, recruiting students who had no previous opportunity for university-level education, and concentrating the weight of their training on a service- and community-based model of education, relying on practicing physician-tutors. Results Over 20,000 students have been enrolled in three years. The six-year program has been extended to all 24 Venezuelan states, relying mainly on Cuban faculty who are practicing Barrio Adentro doctors and who receive postgraduate training in medical education. This "university without walls" has accredited 5,131 Barrio Adentro clinics as teaching institutions; its infrastructure includes other health care delivery facilities plus 855 multipurpose classrooms throughout the country. For the 2006-2007 academic year, the pass rate was 82% for first-year students and 94% for second-year students. Some difficulties persist in student selection, pre-medical preparation, and achieving optimum use of existing resources. Academic, institutional, and external evaluations are ongoing. Conclusion This is the most ambitious example of scaling up of physician training in a single country. The program has been made possible by considerable political will from the Venezuelan and Cuban governments; by the experience acquired through development of the Cuban health system and medical education programs; by the individual commitment of Cuban curriculum developers and physician-tutors; and by ever-more-organized Venezuelan communities. The size of the undertaking, coupled with significant innovations in curriculum, present challenges. The Venezuelan experience - emphasis on training physicians for a revitalized public health sector, accompanied by a paradigm shift in primary care - warrants attention from the international community in the context of the global shortage of health workers and efforts to achieve a more equitable distribution of health services worldwide.

Perspectives from a home based neonatal care program in Brazil's Single Health System

This study aimed to report aspects of how mothers undertake home care of their infants while the latter are kept in a neonatal home care program. It was based on a qualitative approach and institutional analysis related to the gender category was used as theoretical reference frameworks. Data collection was carried out through semistructured interviews with eleven mothers after discharge from the program. Discourse analysis showed that the mothers assessed this form of care as essential, innovative and positive. It is thus considered an effective intervention from a child-integrated-care perspective, since interference of the team in the everyday lives of these women and their children encompassed not only the clinical aspect but affected other dimensions of their lives. It established a partnership with them and helped the mothers to build greater autonomy in caring for their children. However, there is a need for interinstitutional space, which will create the potential for basic health care actions.

A Health System Program To Reduce Work Disability Related to Musculoskeletal Disorders

Musculoskeletal disorders (MSDs) are a frequent cause of work disability, accounting for productivity losses in industrialized societies equivalent to 1.3% of the U.S. gross national product. To evaluate whether a population-based clinical program offered to patients with recent-onset work disability caused by MSDs is cost-effective. Randomized, controlled intervention study. The inclusion and follow-up periods each lasted 12 months. Three health districts in Madrid, Spain. All patients with MSD-related temporary work disability in 1998 and 1999. The control group received standard primary care management, with referral to specialized care if needed. The intervention group received a specific program, administered by rheumatologists, in which care was delivered during regular visits and included 3 main elements: education, protocol-based clinical management, and administrative duties. Efficacy variables were 1) days of temporary work disability and 2) number of patients with permanent work disability. All analyses were done on an intention-to-treat basis. 1,077 patients were included in the study, 7805 in the control group and 5272 in the intervention group, generating 16,297 episodes of MSD-related temporary work disability. These episodes were shorter in the intervention group than in the control group (mean, 26 days compared with 41 days; P < 0.001), and the groups had similar numbers of episodes per patient. Fewer patients received long-term disability compensation in the intervention group (n = 38 [0.7%]) than in the control group (n = 99 [1.3%]) (P < 0.005). Direct and indirect costs were lower in the intervention group than in the control group. To save 1 day of temporary work disability, 6.00 dollars had to be invested in the program. Each dollar invested generated a benefit of 11.00 dollars. The program's net benefit was in excess of 5 million dollars. The study was unblinded. Implementation of the program, offered to the general population, improves short- and long-term work disability outcomes and is cost-effective.

The Franciscan program: a Canadian perspective.

255 “PAIN CAN KILL” was the title of an editorial by the late John Liebeskind in the journal, Pain.1 In that article, he mustered evidence on the nocuous effects of pain and stress on the course of cancer.1 Depression also kills2; while among the many symptoms that bedevil the last days of patients, the cachexia-anorexia syndrome stands out as not only the common cause of dependency and loss of quality of life, but as a syndrome which directly shortens the lives of patients.3 The practice of medicine is based on an understanding that the early identification of a problem will lead to either ready alleviation, or possibly even prevention of the disastrous outcomes that may occur if the problem is not promptly addressed. Is it not logical that we should apply the same thinking to end-of-life care, and apply the principles of palliative care as early in the course of a chronic illness as possible? Nevertheless, this simple concept has been ignored within our health care systems; health professionals, patients and families usually think of hospice/palliative care only when disease is far advanced and death is imminent. The Franciscan Health System program, Improving Care Through the End of Life, which is described in this issue of Innovations in End-of-Life Care, can serve as a model to help us overcome current ignorance about the importance of introducing palliative care concepts at the onset of a chronic, predictably fatal illness. My congratulations to Dr. Pattison, Ms. Trandum, their colleagues and the administration of the Franciscan Health System for implementing a most innovative program. It is important for programs of this nature to establish and maintain a comprehensive database that can demonstrate that enrolled patients have a measured improvement in their quality of life, excellent family-professional interaction, and a high degree of satisfaction with professional caregivers. The data generated may convince skeptics that the rhetoric of palliative care can translate into improved care for patients at a reasonable cost. It is also key because we may learn that, as one would expect from a review of symptom biology, impeccable patient care may improve not only the quality of existence, but also the length of life. Concern has been raised that the application of palliative care in acute care settings may dilute palliative/hospice care, as professionals would be caught up in the urgent activities of the acute care setting, functioning simply as “symptomatologists,” i.e., technicians who cobble together a pharmacological answer to a symptom, but fail to recognize or address the psychosocial components of illness. Thus, they may fail to provide a “warm envelope of care” for patients and families, an approach characteristic of good hospice care. I presume that our colleagues at the Franciscan Health System are answering this concern through ensuring that excellent support services are married with equally excellent treatment of the biological abnormalities created by the disease and its associated symptoms. I am asked to comment from a Canadian perspective on the Franciscan Health System program. I wish I could say that we “got there first,” but I am not aware of a similar Canadian program that identifies patients dying from a variety of chronic illnesses and provides them with a truly “best supportive care” comprehensive program. In the absence of carrying out a survey, I cannot state this as a certain fact; perhaps Canadian readers will be challenged to correct my impression. In our own setting, we are mounting a pilot program whereby patients with inoperable cancer of the pancreas (a disorder with a median

Child survival in Indonesia.

The 1980 infant mortality rate of 107/1000 live births in Indonesia was 2 to 3 times the average rate in surrounding Asian countries. Provincial rates vary from 187 in West Nusa Tenggara to 62 in Yogyakarta. This variation is explained in part by female education levels, access to health facilities, and the impress of health aid and system programs, especially family planning. In addition, mortality rates and the usage of modern health care continue to reflect historical and cultural imprints. A program strategy for improvements in infant and child mortality focus on 4 basic elements: 1) growth monitoring, 2) oral rehydration therapy, 3) breast feeding, and 4) immunization. These efforts are delivered largely through the Expanded Immunisation Programme and the Family Nutrition Programme. A potential major breakthrough in primary health care has been realized with the development of a network of integrated health posts (posyandu) which deliver multiple services more efficiently in rural areas.

Synthesizing the interests of consumers, citizens, and administrators in gathering client feedback

In a large metropolitan county's mental health system program evaluators involved consumer representatives, advisory board, and administrators in a client feedback study. The evaluators presented the groups with a “menu” of possible questions, and members of each group selected items where it would be particularly useful to know the opinions of clients. The groups did not agree about the kinds of questions that were desirable. The evaluators created a survey instrument that included high-priority items from each group. The survey was completed by 205 outpatients in three sites. Clients expressed a nearunanimous opinion about some questions, while on other issues there was no client consensus. In human service systems where decision making is shared by people with potentially conflicting interests, the authors recommend polling groups of decision-makers and then uniting their interests in a study of client feedback.