Municipal Health Care System Research Articles

What proportion of patients need to be tested to realise test and treat goals? Trend analysis of patients screened for HIV within the New York City municipal health-care system

BackgroundNew York City Health and Hospitals Corporation (HHC) is the largest municipal health-care system in the USA, comprising 11 acute-care hospitals and six community clinics. Since 2005, HHC has made HIV testing routine, with the goal of reducing incidence and late-stage diagnosis. In this analysis we aimed to: identify proportional markers to signal that a facility's HIV screening efforts had reached stable, routine levels; and identify a marker that, if maintained, would suggest programme goals would be achieved. MethodsSince 2005, 17 HHC facilities have submitted monthly HIV testing reports. We analysed data from 2006–12 to identify patterns in newly diagnosed patients and to assess the rate of concurrent HIV/AIDS diagnoses. Time trends and associations between the reach of screening and screening outcomes were explored with scattergrams and lowess plots, and we used linear and piecewise-linear mixed effects regression models of these outcomes over time. A linear spline of calendar year with knots at 2008 was the fixed effect, with random intercepts at the facility level. To test the association of screening reach with yield of new HIV diagnoses, we estimated mixed effects piecewise linear models of new HIV diagnosis and concurrent HIV/AIDS diagnosis with a linear spline of screening reach with join points at 10% and 20% as fixed effects, and facility-level random intercepts. FindingsBetween 2006 and 2012, 7 381 847 patients aged 13 years and older were seen at 17 HHC facilities. 1 157 830 unique patients were tested, and 11 781 HIV-positive diagnoses were made, 4963 of them new. Rates of concurrent HIV/AIDS diagnosis for newly diagnosed patients went from 32·26% (190 of 589) in 2006, to 25·27% (94 of 372) in 2012. The proportion of age-eligible patients who were screened went from 9·41% (92 123 of 979 376) in 2006, to 18·03% (198 938 of 1 103 079) in 2012. Facility annual proportions ranged from 5·49% (5505 of 100 248) to 39·23% (3909 of 9964), with nine facilities annually screening 20% or more by 2012. In sites with higher proportions of age-eligible population screened, the proportion of tests leading to new HIV diagnoses declined in a curvilinear fashion. We found that when more than 20% are screened, the yield of new HIV diagnoses levels off at approximately 0·3%. The proportion of newly identified patients with a concurrent HIV/AIDS diagnosis declined almost linearly up to a screening proportion of 40%, at which point the predicted and observed rate of concurrent AIDS diagnosis is zero. InterpretationRoutine HIV screening within health-care systems should see a significant decline in undiagnosed HIV patients if they annually reach 20% of their age-eligible patient population. The goal of reaching patients early in their diagnosis and avoiding concurrent HIV/AIDS diagnoses would appear to be reached through routine screening when 40% of age-eligible patients are screened annually. Screening efforts must consider prevalence when interpreting results for other areas; the prevalence of HIV infection in New York City was 1·36% in 2012. The strength of these results related to concurrent HIV/AIDS rates are limited by the number of facilities reaching rates above 20%. FundingFunding for HIV testing expansion and evaluation was provided by continuing support from the New York City Council and through grants including from New York State Health Foundation and a Gilead Sciences FOCUS Award.

Reducing the Use of Seclusion and Restraint in Psychiatric Emergency and Adult Inpatient Services— Improving Patient-Centered Care

The reduction of seclusion and restraint (S/R) use has been given national priority by the US government, The Joint Commission, and patient advocacy groups. It is associated with high rates of patient and staff injuries and is a coercive and potentially traumatizing intervention. The New York City Health and Hospitals Corporation (HHC) is the largest municipal health care system in the country, with 11 HHC facilities operating psychiatric emergency services and inpatient psychiatric services. HHC operates 1117 adult inpatient psychiatric beds with an average length of stay of 22.2 days that generated over 19,000 discharges in 2009. In 2009, there were over 36,000 psychiatric emergency services visits. HHC's Office of Behavioral Health provides strategic leadership, planning, and support for the operations and quality objectives of these services. In January 2007, the corporate office initiated the Seclusion and Restraint Reduction Initiative, with a sequenced, intensive series of interventions and strategies to help focus the behavioral health leadership and staff on the need for continued culture change toward a more patient-centered and safe system of psychiatric emergency and adult inpatient care. From 2007 to 2009, there was a substantial decline in HHC's overall rate of S/R incidents in inpatient units. The more substantial impact was in the reduced overall time spent in S/R; the reduced frequency of use of S/R; and the reduced likelihood of patient injury from S/R use.

Extensão de Cobertura ou Reorganização da Atenção Básica? A trajetória do Programa de Saúde da Família de Manaus-AM

Este trabalho analisa sete anos de implantação do Programa de Saúde da Família (PSF) de Manaus, procurando identificar mudanças no sistema municipal de saúde a ele relacionadas e capazes de contribuir para a redução de desigualdades em saúde. Contextualiza a gênese do PSF no município, suas características, contradições e limitações, investigando se o programa construiu apenas uma trajetória de extensão de cobertura ou contribuiu efetivamente para a reorganização do modelo de atenção básica à saúde. As categorias de análise priorizaram princípios específicos de gestão do PSF: caráter substitutivo, integração com instituições e organizações sociais, territorialização, planejamento situacional com base na família e na comunidade, participação popular e controle social. A metodologia utilizada foi quali-quantitativa, compreendendo a análise dos dados de duas pesquisas avaliativas da implementação do PSF no município, realizadas em 2001 e em 2006. Os resultados mostram que, em Manaus, o PSF se constitui em uma estratégia de extensão de cobertura, com parcial superposição à estrutura assistencial de atenção básica (AB) preexistente e paralelismo de ações. Dadas as condições de sua implantação, conclui-se que o PSF se expressa como um programa isolado dentro do sistema municipal de saúde, com potencialidade para se converter em estratégia reestruturadora da AB em Manaus. A confluência com a implantação dos Distritos Sanitários poderá contribuir para um caminho de reorientação do modelo assistencial que garanta atenção integral e concretize o direito à saúde.

Employment and sociodemographic characteristics: a study of increasing precarity in the health districts of Belo Horizonte, Brazil

BackgroundThe fundamental importance of human resources for the development of health care systems is recognized the world over. Health districts, which constitute the middle level of the municipal health care system in the city of Belo Horizonte, Brazil, deal with demands from all parts of the system. This research seeks to provide the essential features required in order to understand the phenomenon of increase in precarity of employment in these health districts.MethodsThe legal and human resource management documents used by the Municipal Health Secretariat of the City of Belo Horizonte were adopted as the corpus for this research. In order to analyse the changes in employment (2002–2006), the data were collected from ArteRH, a computerized database dealing specifically with data related to human resources, which began operating in 2001. The workers were classified into permanent and non-permanent groups, and their contractual rights were described. Employment dynamics and changes were examined, concentrating on the incorporation of workers and on their social and employment rights during the period under study. The comparative data for the two groups obtained were presented in frequency distribution tables according to type of employment, sex, age group, level of education and wages from 2002 to 2006.ResultsThere was a clear difference between the permanent worker and non-permanent worker groups as regards existing guaranteed employment rights and social security. The increase in the number of non-permanent workers in the workforce, the growing proportion of older workers among the permanently employed and the real wage reductions during the period from 2002 to 2006 are indicative of the process of growing precarity of employment in the group studied.ConclusionIt is a plausible supposition that the demand for health reforms, along with the legal limits imposed on financial expenditure, gave rise to the new types of contract and the present employment situation in the health districts in Belo Horizonte.

Developing a participatory multidisciplinary team approach to enhance the quality of school start

The article discusses how participatory action research was applied during a three-year project at 27 schools in Norway in order to enhance the quality of school start. A multidisciplinary on-site team approach was developed, supported by workshops and dialogue seminars. External professionals from the supportive municipal health care system and special education/school psychology services assisted children and teachers in the first grade, focusing on early health promotion and support to children at risk of developing problems. The project was reported to improve multidisciplinary teamwork and relationships, to increase focus on developmental and health care issues, to develop professional knowledge and practical skills, to increase support to local educational staff, and to provide a better school-start for all and particularly vulnerable children. Local creativity and ownership within supportive administrative structures were reported as promoting factors, while available time and external professional resources were the main constraints. The building of learning partnerships based on face-to-face interaction appeared to be a particular strength of the approach.

Reasons for consultation and explanations of illness among Finnish primary‐care patients

AbstractThe aim of this study is to describe triggers to consultation, and to further understanding of how patients construct explanations for what is wrong with them. Patients consulting a general practitioner were interviewed about the process that had led to their consultation and explanations for the causes of their illness. The results show that the factors which trigger professional consultation are related to the everyday demands of work, home and other people on the one hand, and to the interpretation of bodily symptoms on the other. Characteristically, symptom interpretation often involves a veiled dialogue with the tax‐funded municipal health care system about a justification for the lay diagnosis. The results further show a domination of biomedical illness explanations among the patients studied. A third of the explanations concerned infectious, toxic and noxious agents, and a quarter constitutional defects in the body. Ten per cent were philosophical and metaphysical, and 16 per cent psychosocial in nature. The remainder were based on life style and risk behaviour, and on problems of medical care. The results are discussed from the standpoint of lay and professional models of explanation for illness.