Towards quality and cost-effective health care

Although rich cumulative evidence exists on nursing's effectiveness, few policymakers and healthcare executives apparently are familiar with it. To make such scientific-based knowledge more available so that it can be considered and integrated in healthcare policy and reform, the WHO Collaborating Centre at Mount Sinai Hospital, Toronto, Canada, complied and reviewed research evidence about how nursing services contribute towards cost effectiveness and quality health outcomes. Below, a summary of its findings.     

Ensuring health care quality: a purchaser's perspective--a health care coalition

This paper explores how one health care purchasing coalition in Minnesota, the Buyers Health Care Action Group (BHCAG), has taken an active role in restructuring its local health care market. BHCAG started with the belief that the consumer should be the motivating force in health care delivery. Unfortunately, providing consumers with the information and incentives they need to make informed, effective health care decisions has triggered numerous problems. This paper examines groups of providers who network to form care systems, and explores the roles of consumers, employers, and health plans in the current market. It identifies specific methods for gathering data and distributing information to the consumer, and discusses the problems associated with attempting to implement quality improvement, as well as the questions that arise when the market does not support those improvements.     

Increased competition and the quality of health care

Available information does not indicate either that quality has deteriorated as price competition has increased or that quality has improved. To reward plans for providing what consumers want, public and private policies have crucial roles in the following areas: mandating minimal requirements for plans; funding research to improve knowledge and methods related to quality-of-care assessment; publication of quality-of-care information; selective contracting and regionalizing of services; and payment for physician services. Learning what degree of trade-off between cost versus quality and other benefits is acceptable to consumers will be an iterative process that informs future policies to safeguard the quality of care.     

The pitfalls of palliative care

An eight-year-old Highland pony which had previously shown normal laryngeal function, underwent general anaesthesia for surgical treatment of a mandibular sinus. During its recovery from the anaesthesia, the pony suffered great respiratory distress and stridor, due to total bilateral laryngeal paralysis and pulmonary oedema. The animal was immediately given a temporary tracheostomy. Some hours later, postoperative myositis developed; it resolved within two days and the pony's laryngeal function returned to normal during the following year.     

Chronobioengineering toward a cost-effective quality health care

The current disease-cure-oriented health care system does too little too late for too few. Engineering for concomitantly resolving the external conditions and the internal schedules, chronoengineering in the broad sense, could change this status quo into a system that recognizes environmental and organismic risk early, blows a whistle as a minimum and acts automatically, as an optimum. The chronobioengineering feature (of the broader chronoengineering for external as well as internal monitoring and decision helping) would gain new individualized information from the resolution of predictable variations that occur within the physiologic range, the chronomes, genetically anchored multifrequency rhythms and trends. Their resolution by chronobiometry provides a more precise and more accurate mean value (than the arithmetic mean) along with new dynamic endpoints for improved screening, diagnosis, prognosis, and timely and timed treatment. Trends are those with growth, development, maturation and aging, and also those with risk elevation or disease and treatment. Risk elevation may change amplitude or timing, but not necessarily the mean. The implementation of engineering for concomitantly resolving the external and internal schedules depends on telecommunications and telehygiene as well as telemedicine for (i) universal chronobiologic education (to assume self-responsibility and self-help in health care), (ii) physiologic monitoring (complemented as a sine qua non by chronobiologic data analysis and interpretation of the results) and (iii) the monitoring of pertinent environmental conditions. Thus, the number of cases of catastrophic diseases could be reduced and quality (since preventive) health care made available to all.     

Total quality management in behavioral health care

The literature on total quality management or continuous quality improvement in the behavioral health care field is just beginning to emerge. Although most of the evidence on its effectiveness remains anecdotal, it seems clear that it can work in behavioral health care organizations with strong leadership support and a long-term commitment.     

Modern techniques for quality control and quality management in gynecological health care

Information technologies may contribute in many effective ways to total quality management. Their supporting capacity concerns areas such as clinical documentation and quality control as well as problem analysis, quality assurance and improvement and knowledge management. Here however, a great deficit of the available departmental information systems must be stated.     

Community health centers and quality of care: a goal to provide effective health care to the community

The uniqueness of community health centers provides for a sound environment for total quality management (TQM). Structure, process, and outcome are valued equally under TQM. With strong management leadership and a framework for quality of care, community health care specialists (e.g., advanced practice nurses) can easily incorporate the TQM measurement criteria in their daily practice routines. By applying the principles of TQM, the community health center will advance toward its goal of enhancing the effectiveness of health care delivery to a community and its members in partnership with the community.     

Standards and quality control: problems and pitfalls

The proliferation of standards and quality assurance programs is posing a major problem for mental health administrators. The authors review some of these problems and emphasize the differences between cost and quality controls. They propose that quality controls be judged on their ability to improve patient care and suggest that administrators consider the establishment of quality control offices.     

Competition and quality in health care: the UK experience

Intraindividual variability and the effects of menstrual cycle phase on CYP2D6 activity were evaluated by dextromethorphan phenotyping in 20 Caucasian normal volunteers. Dextromethorphan 30 mg was administered to 10 men every 14 days for 3 months, and to 10 premenopausal women during the mid-follicular and mid-luteal phases of each menstrual cycle for three complete cycles. Urinary dextromethorphan/dextrorphan molar ratios were obtained after an overnight urine collection. Ten women and nine men were extensive metabolizer phenotypes, and one man was a poor metabolizer phenotype (confirmed by genotyping). There was no difference in dextromethorphan metabolic ratios between the mid-follicular (mean +/- SD: 0.00728+/-0.00717) and mid-luteal (0.00745+/-0.00815) phases of the menstrual cycle (P = 0.88). Also, no significant difference was found in the intraindividual variability of the metabolic ratios between the two phases (P = 0.80). No statistically significant sex difference in CYP2D6 activity was found between men (0.00537+/-0.00431) and women (0.00737+/-0.00983) extensive metabolizers (P = 0.84). For all individuals, intraindividual variability in dextromethorphan ratios ranged from 12.1-136.6% with a median of 36.7%. Because hormonal fluctuations within the mid-follicular and mid-luteal phases of the menstrual cycle do not appear to affect CYP2D6 activity, pharmacokinetic or clinical investigations of CYP2D6 substrate activity may not require menstrual cycle phase stratification. Because baseline metabolic ratios may fluctuate an average of 37%, repeat baseline and treatment phenotyping assessments should be obtained for accurate determination of a given drug's effect on CYP2D6 activity when measured by dextromethorphan.