In vitro metabolism of cyanohydroxybutene: formation of a glutathione-S-transferase catalyzed product

This paper examines the financing of elderly health care in Japan for medical institutions, nursing homes, and at home. The analysis demonstrates that the conventional figures for elderly health expenditures in Japan systematically underestimate the real costs by excluding the costs of uninsured services, nursing homes, and home health care. The paper estimates these costs and shows that they add about 10% to the conventional figure for elderly health care costs in Japan. This inquiry also shows how government policy for health care financing shaped distinctive Japanese patterns of elderly care provision. The financing system provided a hidden subsidy--through national health insurance coverage of long-term hospitalization--that encouraged high institutionalization rates of elderly in medical facilities. Public financing for long-term elderly hospitalization, however, has not been matched by government attention to quality of care, resulting in serious quality problems and reflecting a social trade-off between cost and quality. Also, until recently the financing system rarely reimbursed home health care, thereby creating strong disincentives to the development of formal home health care services. This analysis has important implications for reforms now being considered by the Japanese government in the financing and provision of health care for the elderly, especially the limitations of relying on reimbursement price policy. The reforms could have unintended negative consequences for equity, efficiency, and quality of care.     

Primary care in psychiatry residency training

The author summarizes patient perspectives and government initiatives that have fostered closer medicine-psychiatry cooperation and more comprehensive treatment of patients. Despite the growing numbers of people requiring more formal mental health care, most patients are being treated by primary health care providers. This trend will continue as long as there is a decline in the number of medical students entering psychiatry. The author summarizes several general principles that psychiatry residency program directors should consider in designing primary care experiences for their residents and for medical students rotating on their services: longitudinal primary care experiences in organized medical care settings, training in basic medical principles and techniques, and instruction in the biopsychosocial model of disease. The author also recommends there specific training experiences for psychiatry residents that would enhance their ability to provide more effective mental health services to primary care physicians and their patients: consultation psychiatry, primary mental health care, and general psychiatry. The author concludes that medical students, through their contact with primary care-oriented psychiatry residency programs, would be more attracted to psychiatry as a specialty choice and that residents, upon completion of training, would be more inclined to practice in primary care settings.     

Innovative service redesign and resource reallocation: responding to political realities, mental health reform and community mental health needs

General hospital mental health programs in large inner city communities face challenges in developing responsive services for populations facing high rates of serious mental illness, substance abuse, homelessness, and poverty. In addition provincial political pressures such as Mental Health Reform and hospital restructuring have caused general hospital mental health programs to reevaluate how services are delivered and resources are allocated. This paper describes how one inner city mental health service in a university teaching setting developed successful strategies to respond to these pressures. Strategies included: (a) merging two general hospital mental health services to pool resources; (b) allocating resources to innovative care delivery models consistent with provincial reforms and community needs; (c) fostering staff role changes, job transitions, and the development of new professional competencies to complement the innovative care delivery models; and (d) developing processes to evaluate the effects of these changes on client.     

Rural psychiatry in developing countries

During the last two decades several initiatives have been taken to improve psychiatric services in low-income rural areas in developing countries. They have included the formulation of national mental health programs and establishment of pilot programs for integration of mental health care with primary health care in India, Iran, and other countries in Asia, Africa, and South America. The psychiatrist has multiple roles to play in meeting the many challenges of providing mental health care in rural areas in developing countries.     

The Polish experience of quality improvement in primary care

THE POLISH HEALTH CARE SYSTEM: The health care system in Poland is based on a model typical of east-central European countries, with features such as state-owned health care organizations, centralized management and administration, and primacy of access to care over quality. Poorly planned and uncoordinated reforms have been undertaken to transfer some of the authority for health service management to local governments. PRIMARY HEALTH CARE IN POLAND: The reform of the health care system entails substitution of family physician-based for medical specialist-based primary care. Newly trained family physicians, as the first to start private surgery clinics financed from public sources, are the forerunners of the comprehensive reform and property structure transformation. MAKING THE TRANSITION FROM QUALITY ASSURANCE TO QUALITY IMPROVEMENT: Since the early 1990s, more and more organizations, individuals, and professional groups have begun to perceive health care regulations and other external control mechanisms as ineffective. Attempts have been made to replace periodic, restrictive activities with systematic continuous quality improvement efforts. Systems of voluntary accreditation are being developed and fostered. Groups have started meeting to develop medical practice guidelines and conduct peer review. Concern about quality of health care services is now reflected in the Polish legislation for the first time, as well as in numerous local and nationwide projects and publications. CONCLUSION: Despite some successes, the pioneers of quality improvement (QI) still have a long way to go. Continuation of educational activities and creation of a system of motivation for the development, of QI in primary care should be prioritized and encouraged.     

Palliative care in undergraduate medical education. Status report and future directions

OBJECTIVE: To describe the status of palliative care education in the undergraduate medical curriculum and to offer recommendations for improvement. DATA SOURCES: Review of literature on palliative care and of recently submitted grants on medical education for end-of-life care. STUDY SELECTION: English-language reports of educational programs targeted toward medical students were examined, as well as surveys of medical schools. DATA EXTRACTION: Studies were reviewed by the authors to assess the quality of the educational program, evaluation methodology, and conclusions. From over 9000 citations on palliative care and related topics that were retrieved from MEDLINE searches from 1980 through 1995, and from reviewing 14 palliative care journals published from 1985 through 1996, 310 articles were identified that addressed medical education for end-of-life care, and 180 were carefully examined. DATA SYNTHESIS: While nearly all medical schools offer some formal teaching about end-of-life care, there is considerable evidence that current training is inadequate, most strikingly in the clinical years. Teaching about palliative care is received favorably by students, positively influences student attitudes, and enhances communication skills. However, curricular offerings are not well integrated; the major teaching format is the lecture; formal teaching is predominantly preclinical; clinical experiences are mostly elective; there is little attention to home care, hospice, and nursing home care; role models are few; and students are not encouraged to examine their personal reactions to these clinical experiences. CONCLUSIONS: The increasing attention to palliative care education has created major opportunities for improving education about care at the end of life. Educational programs should be rigorously evaluated to identify best educational practices.     

Differences in religiousness among black and white women with breast cancer

OBJECTIVE: To answer the question, "does CME work?" by reviewing the effectiveness of continuing medical education (CME) and other related educational methods on objectively-determined physician performance and/or health care outcomes. These interventions include educational materials, formal, planned CME activities or programs, outreach visits such as academic detailing, opinion leaders, patient-mediated strategies, audit and feedback, reminders, or a combination of these strategies. METHODS: MEDLINE, ERIC, NTIS, the Research and Development Resource Base in CME and other relevant data sources including review articles were searched for relevant terms, from 1975 to 1994. Of those articles retrieved, randomized controlled trials of educational strategies or interventions which objectively assessed physician performance and/or health care outcomes were selected for review. Data were extracted from each article about the specialty of the physician targeted, the clinical subject of the intervention, the setting and the nature of the educational method, and the presence or degree of needs assessment or barriers to change. RESULTS: More than two-thirds of the studies (70%) displayed a change in physician performance, while almost half (48%) of interventions produced a change in health care outcomes. Community-based strategies such as academic detailing (and to a lesser extent, opinion leaders), practice-based methods such as reminders and patient-mediated strategies, and multiple interventions appeared to be most effective activities. Mixed results and weaker outcomes were demonstrated by audit and educational materials, while formal CME conferences without enabling or practice-reinforcing strategies, had relatively little impact. CONCLUSION: Strategies which enable and/or reinforce appear to "work" in changing physician performance or health care outcomes, a finding which has significant impact on the delivery of CME, and the need for further research into physician learning and change.     

Help seeking for mental health care among poor Puerto Ricans: problem recognition, service use, and type of provider

OBJECTIVES: This study examines the effects of health, predisposing, and enabling factors on recognition of a mental health problem, use of formal mental health care, and contact with a specialized mental health provider. METHODS: Interviews were conducted with a probability sample of 3,435 adults. The variables examined include measures of mental health; social and demographic factors; and enabling factors relevant to the help-seeking process. RESULTS: Subjective and objective measures of mental health were associated with the recognition of a mental health problem. The objective assessment of definite need for services was relevant for the use of formal services. However, the subjects' perception of poor mental health was strongly related to receiving care from a mental health specialist. Although interaction with social networks is associated with use of formal services, low economic strain is related to receiving care from the specialty sector. CONCLUSIONS: The results support the importance of using multiple measures of mental health problems. The finding that individuals' perceived economic strain increases the likelihood of receiving specialized care suggests that studies of economic barriers to the use of mental health services might benefit from the adoption of measures that assess perceived economic circumstances.     

In search of value: an international comparison of cost, access, and outcomes

The United States spent the most resources on health care of all the twenty-nine industrialized countries in 1996 by a wide margin. Managed care and other recent initiatives have been credited with slowing the rate of increase in the U.S. health care spending in recent years. Although the rate of increase slowed, it was still more rapid than the rate in most other industrialized countries between 1990 and 1996. Among the twenty-nine industrialized countries, the United states had the lowest percentage of its population eligible for publicly mandated insurance in 1995. Since 1960 Greece, Korea, and Mexico have surpassed the United States on this measure. AMong the twenty-nine industrialized countries, only the United States had less than half of its population eligible for publicly mandated health insurance in 1995. The United States appears to be comparable to the other G7 countries in terms of access to physicians, in-patient hospital services, and pharmaceuticals. However, on outcomes indicators such as life expectancy and infant mortality, the United States is frequently in the bottom quartile among the twenty-nine industrialized countries, and its relative ranking has been declining since 1960.     

State health care reforms: how they affect children and adolescents with emotional disorders and their families

This article reports on the Health Care Reform Tracking Project, a national study designed to describe and analyze state health care reforms and their impact on children and adolescents with emotional disorders and their families. It summarizes the results of the baseline survey of states conducted in 1995, exploring the nature and extent of the reforms in which states are engaged, most of which involve applying managed care technologies to their Medicaid programs. Trends across states are identified with respect to mental health service delivery, particularly with respect to children and adolescents. The article concludes with a discussion of issues and concerns related not only to mental health service delivery for children and adolescents with emotional disorders and their families but also to the systems of care that have been developing over the past decade to serve them. Some of these concerns include the lack of pilots or demonstrations, limited mental health coverage in some reforms, the lack of integration between mental health and substance abuse systems, the lack of special provisions for children, the need for more reliable bases for deriving capitation rates, the limited incorporation of systems of care, the need to incorporate interagency treatment planning and service delivery approaches, the lack of outcome measures specific to and appropriate for children, and the need for greater family involvement in the planning and implementation of these reforms.     

Care for Canada's frail elderly population: fragmentation or integration?

Budget constraints, technological advances and a growing elderly population have resulted in major reforms in health care systems across Canada. This has led to fewer and smaller acute care hospitals and increasing pressure on the primary care and continuing care networks. The present system of care for the frail elderly, who are particularly vulnerable, is characterized by fragmentation of services, negative incentives and the absence of accountability. This is turn leads to the inappropriate and costly use of health and social services, particularly in acute care hospitals and long-term care institutions. Canada needs to develop a publicly managed community-based system of primary care to provide integrated care for the frail elderly. The authors describe such a model, which would have clinical and financial responsibility for the full range of health and social services required by this population. This model would represent a major challenge and change for the existing system. Demonstration projects are needed to evaluate its cost-effectiveness and address issues raised by its introduction.     

The CMRF-35 mAb recognizes a second leukocyte membrane molecule with a domain similar to the poly Ig receptor

In order to understand the problems of undesired infertility in the Gambia, where the desire for children and fertility is very high, a population based estimate of the frequency of sub-/infertility was undertaken. A survey was used in a representative random sample of the population. The study included an assessment of health care available for infertile couples in the different types and levels of the formal and traditional health system. Primary sterility was found to be fairly uncommon (3%), and secondary infertility to be more frequent (6%). Half of the infertile couples failed to seek formal health care, and they had to reach a certain level of care in order to be properly managed. As investigations are very basic and treatment possibilities scarce, many forms of alternative care are often sought. In addressing reproductive health in developing countries, a systematic primary health care approach to infertility in rural areas with limited resources should be developed.     

St Jude Children's Research Hospital's International Outreach Program

Over 80% of children with cancer live in developing countries, where access to medical services is limited to varying degrees. In many of these countries, economic conditions and general health care have improved sufficiently to permit the development of more sophisticated medical services. The introduction of pediatric oncology programs becomes appropriate as deaths from malnutrition and infections decrease and cancer emerges as an important cause of childhood mortality. In the absence of such services, the worldwide war against pediatric cancer will ultimately be lost because of the rapidly growing pediatric populations in developing countries that now lack the facilities and expertise to treat childhood malignancies. We believe that the development of pediatric cancer centers in many of these countries is both appropriate and feasible. Partnerships in which established pediatric oncology centers work with the governments and private sectors of developing nations to implement key facilities are an efficient and cost-effective way to introduce such services. The challenges of these outreach efforts are significant -- as are the expected benefits.     

Doctor in the house: trends in GPs home visiting in Croatia 1990-1995 compared to current trends in USA and UK

During the period of intensive economic, political and epidemiological transition in Croatia (1990-1995), significant changes in patterns, intensity and organization of home visiting were registered and reported. Quantitative instruments were employed to determine changes in trends of financing, health manpower policy and use of services before and after 1993 health care reforms. The qualitative part of research (e.g., cross-sectional and cross-national comparison of trends) was used to compare the significance of a reduction in the number of home visits as well as how its pattern fitted into the international trends (outburst of home visits in the USA and stagnation or decrease in the UK).     

Health care systems in transition: People's Republic of China. Part I: An overview of China's health care system

The People's Republic of China for the first 30 years of its existence had a centrally directed health care system which achieved impressive health gains for its population. By emphasizing prevention; organizing innovative, low-cost, locally controlled health services; and promoting accessible primary health care in rural areas, China increased life expectancy for most of its people, dramatically reduced levels of infant mortality, and eradicated or controlled a range of infectious and parasitic diseases. Since 1978, however, China's leadership has come to depend more upon market forces than central direction and planning to achieve economic growth. These new orientation has had major effects upon the organization and financing of health services. After more than a decade of economic and agricultural reform, China still has problems providing good-quality, affordable, and equitable health services for the majority of the rural population and both urban and rural poor. The need to pay for health care considerably exacerbates poverty in China. This paper describes the structure of government and the health care system, the nature of change during 1978-90, the impact of the reforms upon health status and health care delivery, and future challenges.     

Education programs in US medical schools, 1995-1996

We present herein data on US medical education programs and describe how medical schools are adapting to a changing health care environment. The data mainly derive from the 1995-1996 Liaison Committee on Medical Education Medical School Questionnaire, which had a 100% response rate. The data indicate that in the 1995-1996 academic year there were 91 451 full-time faculty members in basic science and clinical departments, a 1.6% increase from 1994-1995. In clinical departments, major increases occurred in emergency medicine (a 10.6% increase in full-time faculty) and family medicine (a 13.5% increase). Applicants for the class entering in 1995 numbered 46 591, an increase of 2.7% from 1994; however, the number of first-time applicants decreased slightly (0.6%). Of the 17 357 applicants accepted, 2179 (12.6%) were members of underrepresented minority groups. Health system changes are affecting medical school clinical affiliations. During the past 2 years, 42 schools saw a merger, acquisition, or closure involving medical school-owned or medical school-affiliated hospitals used for core clinical clerkships. At 15 sites, this change affected the distribution of students across clinical sites. In 1995-1996, 40 medical schools or their universities owned a health maintenance organization or other managed care organization, 93 schools contracted with a managed care organization to provide primary care services, and 96 schools contracted with managed care to provide specialty services. During the past year, 57 schools acquired primary care physician practices, and 70 started primary care clinics in the community.     

Paradoxes of GP fundholding: contracting for community health services in the British National Health Service

The expansion of GP fundholding (GPFH) is central to the British government's attempt to maintain the revolution under way in the National Health Service (NHS). Evaluations of the NHS reforms have portrayed GPFH as an important mechanism for competition, and GPFH's bargaining power is reported to have secured significant changes in health service provision. However, these developments have been acknowledged to be less applicable in relation to community health services (CHS) than acute hospital services. On the basis of case studies of the process of contracting for CHS, GPFHs are shown to display ambivalent and sometimes contradictory views which have to be related to broader policy developments in general practice and primary care. Although this paper focuses on the British situation, many of the issues raised by reforms in primary and community health services have implications for developments in other Western health care systems.     

Ethics of resource allocation in developing countries: the case of Sri Lanka

The issues of prioritization of health care services and allocation of resources have recently received increasing attention and discussion. Several reports have been published by governments in different countries and the issues are discussed in many recent books and papers. In this paper the focus is on the problems faced by a developing country when allocation of health care resources is considered. We consider these issues under three headings and exemplify the situation in a developing country by taking Sri Lanka as an example. Firstly the evidence to formulate an ethical basis for the existing health care system in Sri Lanka is discussed, in particular the problem of defining a minimum quality of health care for the population. Secondly, we consider the issues which arise when we want to formulate the ethical basis for health sector reform. In particular, we examine current World Bank proposals. We shall argue that there are a number of important conceptual and ethical issues that have not been properly addressed in the various policy documents. Finally, we introduce our own alternative ethical framework for policy reform.     

Use of formal and informal sources of mental health care among older African-American public-housing residents

BACKGROUND: Elderly residents of public housing have high rates of psychiatric disorders, but most of those in need of care do not use any mental health service. This study examines the use of formal and alternative informal sources of mental health care in a sample of elderly African-American public-housing residents. METHOD: Data from an epidemiological survey of six Baltimore public-housing developments for the elderly (weighted N = 818) were analysed to examine the utilization of mental health services by older African-American residents. Logistic regression analyses were used to determine correlates of using formal and informal sources by those needing mental health care. RESULTS: Thirty-five per cent of subjects needed mental health care. Less than half (47%) of those in need received any mental health care in the previous 6 months. Residents in need were more likely to use formal (38.5%) than informal sources (18.6%) for care. The strongest correlates of using formal providers were substance use disorder (OR = 15.62), Medicare insurance (OR = 10.31) and psychological distress (OR = 10.27). The strongest correlates of using informal sources were perceiving little or no support from religious/spiritual beliefs (OR = 21.65), cognitive disorder (OR = 19.71) and having a confidant (OR = 15.07). CONCLUSIONS: Contrary to elderly African-Americans in general, those in public housing rely more on formal than informal sources for mental health problems. Nevertheless, both sources fail to fill the gap between need and met need. Interventions to increase identification, referral and treatment of elderly public-housing residents in need should target general medical providers and clergy and include assertive outreach by mental health specialists.     

General practice fundholding: progress to date

BACKGROUND: The cornerstone of the National Health Service (NHS) reforms was the establishment of an internal market, which separated purchasing and providing roles. As purchasers of care, general practice fundholders were seen as a pivotal part of the 'new patient-led NHS', which was intended to lead to improved cost-containment and cost-effectiveness, quality of care, and patient choice and empowerment. AIM: To review published evidence of the extent to which these objectives may have been achieved over the past six years. METHOD: Keyword search of on-line databases (MEDLINE and Econ-lit) from 1990 to 1996, plus manual search of references within those articles identified. RESULTS: In the absence of any formal evaluation of fundholding, it is difficult to assess the overall success of this reform. However, in terms of cost-containment and cost-effectiveness, there is mixed evidence. In some areas, such as prescribing, the evidence suggests cost-savings, although the evidence is less clear on reductions or changes in referrals. There is also evidence that suggests that improvements in prescribing may have been achieved at substantial additional administration and transaction costs. With respect to quality of care, the evidence suggests that, although quality in the procedural aspects of health provision has improved, there is little evidence about how health outcomes may have been affected. In terms of patient choice and empowerment, the evidence suggests that, whilst general practitioner choice of secondary providers has improved, little progress has been made with regard to increased consumer choice. CONCLUSION: Evidence concerning the success or otherwise of general practice fundholding over the past six years is incomplete and mixed. The major deficiency concerns any effect on health outcomes that may be the result of fundholding. Until such research is conducted, the jury will have to remain out on whether fundholding has secured improved efficiency in the delivery of health care.