bluuebunny/crossref_metadata_2025 huggingface dataset:
Evidence-Based Analysis of the Efficacy for Operative Treatment of Hallux Rigidus
Authors: McNeil Daniel S. , Baumhauer Judith F. , Glazebrook Mark A.
Published: January 2017

Background:

The aim of this article is to provide an evidence-based literature review and assessment of the quality of literature regarding operative interventions for hallux rigidus.

Methods:

A comprehensive evidence-based literature review of the PubMed database was conducted on June 24, 2011, identifying 586 articles, of which 135 were relevant in assessing the efficacy of common operative interventions for hallux rigidus. The 135 studies were then assigned a level of evidence (I-V) to denote quality. They were then reviewed to provide a grade of recommendation (A-C, I) in support of or against the operative intervention in treatment of hallux rigidus.

Results:

Based on the results of this evidence-based review, there is fair evidence (grade B) in support of arthrodesis for treatment of hallux rigidus. There is poor evidence (grade C) in support of cheilectomy, osteotomy, implant arthroplasty, resection arthroplasty, and interpositional arthroplasty for treatment of hallux rigidus. There is insufficient evidence (grade I) for cheilectomy with osteotomy for treatment of hallux rigidus.

Conclusion:

There are no consistent findings in comparative studies that are properly powered with validated and appropriate outcome measures to allow any definitive conclusions on which procedure is best. However, the grade B recommendation assigned to arthrodesis may make it the logical leading candidate for future high-quality randomized controlled trials. Clearly, further studies—ideally, high-quality Level I randomized controlled trials with validated outcome measures—are needed to allow stronger recommendations to be made.

Level of Evidence:

Level III, systematic review.
Achilles Tendon Rupture in Women
Authors: Vosseller J. Turner , Ellis Scott J. , Levine David S. , Kennedy John G. , Elliott Andrew J. , Deland Jonathan T. , Roberts Matthew M. , O’Malley Martin J.
Published: January 2017

Background:

The incidence of Achilles rupture appears to be less in women, although this notion has not been specifically investigated in the literature.

Methods:

The medical records of 7 foot-and-ankle orthopaedic surgeons at 1 institution were reviewed by Current Procedural Terminology (code 27650) and International Classification of Diseases–9 (code 727.67) to establish all Achilles tendon ruptures seen and/or treated by these surgeons. Sex, age, side, and mechanism of injury were recorded. Whether the patient had an acute Achilles tendon rupture or nonacute Achilles pathology was also noted.

Results:

A total of 468 patients were identified, of whom 358 had acute ruptures: 302 male and 56 female (5.39:1). Patients with acute ruptures were significantly younger than those with nonacute pathology (43.8 vs 55.1, P < .001). For acute ruptures, the mean age was not significantly different between men and women (43.9 vs 43.2; P = .780). Athletic activity was causative in 243 of 302 men (80.5%) and in 40 of 56 women (71.4%). This difference was not statistically significant ( P = .130). Six men (2.0%) and 6 women (10.7%) had comorbidities that were thought to increase their risk of rupture ( P = .005).

Conclusion:

Achilles tendon rupture is more common in men than women. Previous studies using the aforementioned codes to identify patients without chart review may have overestimated the number of women with acute Achilles tendon rupture.

Level of Evidence:

Level III, retrospective comparative series.
Effect of Various Hallux Valgus Reconstruction on Sesamoid Location
Authors: Huang Eddie H. , Charlton Timothy P. , Ajayi Samuel , Thordarson David B.
Published: January 2017

Background:

The correction of sesamoid subluxation is an important component of hallux valgus reconstruction with some surgeons feeling that the sesamoids can be pulled back under the first metatarsal head when imbricating the medial capsule during surgery. The purpose of this study was to radiographically assess the effect of an osteotomy on sesamoid location relative to the second metatarsal.

Methods:

This is a retrospective radiographic study review of 165 patients with hallux valgus treated with reconstructive osteotomies. Patients were included if they underwent a scarf or basilar osteotomy for hallux valgus but were excluded if they had inflammatory arthropathy or lesser metatarsal osteotomy. A modified McBride soft tissue procedure was performed in conjunction with the basilar and scarf osteotomies. Each patient’s preoperative and postoperative radiographs were evaluated for hallux valgus angle, intermetatarsal 1-2 angle, tibial sesamoid classification, and lateral sesamoid location relative to the second metatarsal.

Result:

The greatest correction of both hallux valgus and intermetatrsal 1-2 angle was achieved in basilar osteotomies (20.6 degrees and 9.7 degrees, respectively), then scarf osteotomies (14.4 degrees and 8.7 degrees, respectively). Basilar and scarf osteotomies both corrected medial sesamoid subluxation relative to the first metatarsal head an average of 2-3 classification stages. All osteotomies had minimal lateral sesamoid location change relative to the second metatarsal.

Conclusion:

The majority of sesamoid correction correlated with the intermetatarsal 1-2 correction. The concept that medial capsular plication pulls the sesamoids beneath the first metatarsal (ie, changes the location of the sesamoids relative to the second metatarsal) was not supported by our results.

Level of Evidence:

Level III, retrospective case series.
Exploring Anger in the Hostile Media Process: Effects on News Preferences and Source Evaluation
Authors: Arpan Laura M. , Nabi Robin L.
Published: January 2017

Most studies of news bias judgments and news consumption do not consider the likely emotional responses to news content, and theoretical arguments suggest that approach emotions, like anger, may actually motivate more, not less, news consumption. An experiment found support for hypotheses that bias judgments would positively correlate with anger responses, and anger responses would associate not only with greater criticism of the reporter but also more, rather than less, interest in additional news stories containing both identity-threatening and identity-bolstering content.
Exploring Factors in the Hostile Media Perception: Partisanship, Electoral Engagement, and Media Use Patterns
Authors: Oh Hyun Jee , Park Jongmin , Wanta Wayne
Published: January 2017

Using survey data from 2000 and 2007, this study examines individual-level variables influencing the hostile media perception (HMP). Specifically, the study explores how HMP in election coverage is determined based on people's political party identification and its strength, electoral engagement, and media use. HMP was greater for Republicans compared to Democrats in 2000 and 2007. Higher levels of partisanship as well as electoral engagement encouraged HMP.
The Emergence of Nano News: Tracking Thematic Trends and Changes in U.S. Newspaper Coverage of Nanotechnology
Authors: Dudo Anthony , Dunwoody Sharon , Scheufele Dietram A.
Published: January 2017

Mediated messages can influence awareness and nascent perceptions of novel or new issues. Nanotechnology is one such issue. This study explores descriptive and thematic characteristics of journalistic coverage of nanotechnology over a twenty-year span using computer-aided content analysis, finding an emphasis on research throughout the period with an increasing focus on both business and health aspects of nanotechnology. Later stories are more likely to address potential risks, while the regulatory dimensions, environmental implications, and uncertainty inherent in this emerging technology remain largely unaddressed.
Political Socialization: Modeling Teen Political and Civic Engagement
Authors: Warren Ron , Wicks Robert H.
Published: January 2017

Research on adolescent political and civic engagement has focused on a wide variety of socializing agents, including parents, school, peers, and the media. This study builds an explanatory model that connects macro-level (e.g., religion, education) and micro-level (parents, school curricula, and media) socialization agents. Using the ecological systems model of child development, the study shows a pattern of influence involving parents' political engagement and civic engagement, as well as teens' use of online political media. Media influence in the context of other factors is noted, along with the model's implications for further research on political socialization.
Using Time Series Analysis to Measure Intermedia Agenda-Setting Influence in Traditional Media and Political Blog Networks
Authors: Meraz Sharon
Published: January 2017

Using time series analysis to gauge intermedia agenda setting in a sample of eighteen U.S. political blogs, two elite traditional news entities, and their eleven political newsroom blogs across three issues in 2007, this study reveals that traditional media were unable to set political blog agendas. Ideologically diverse political blog networks were also able to set traditional media's online news agenda, and, to a lesser extent, their newsroom blog agenda. Findings point to a dilution of traditional media's singular agenda-setting influence and to greater interdependence between traditional media and political blogs than suggested by hyperlink studies.
"It's Just Me, My Family, My Treatments, and My Nurse.. .oh, yeah, and Nintendo"*: Hildegard Peplau's Day with Kids with Cancer
Authors: Kelley Stefanie J.
Published: January 2017

Dr. Hildegard Peplau's interpersonal relations theory is applied to the nursing care of pediatric oncology patients. The nursing metaparadigm framework is the person, the environment, health, and nursing. In this article, a fictitious interpersonal relation between a pediatric oncology patient and Dr. Peplau is created. The person is represented by the patient. The environment is represented by the family. Health is represented by the treatments. Nursing is represented by Dr. Peplau. Although Dr. Peplau's theory is used in psychiatric nursing, the relations and roles of the interpersonal process are applied easily to the clinical arena of pediatric oncology.
The Sense of Relationship in Women Who Have Encountered Abuse
Authors: Farrell Marian L.
Published: January 2017

BACKGROUND. This study was built on previous work (Farrell, 1992) that explored the sense of healing in women who encountered abuse. Relationship, one of the main themes of the study, was defined as the integration of all aspects of the self and a sense of connectedness between self and others. A sense of relationship was a central aspect in the healing of women who participated in the study. The relational model used as part of the conceptual framework for the study describes bow a woman's sense of self develops because of the relationships that occur within her life.

OBJECTIVES: The purpose of the study was to explore the sense of relationship in women who encountered abuse.

STUDY DESIGN: A phenomenologic approach was used. This method involves description, reduction, essences, and intentionality. Seventeen women who responded to notices in local newspapers agreed to complete the study. The data collection methods used in the study included in-depth interviewsfield notes, and demographic data sheets.

RESULTS: The results of the study provided an understanding of the relational sense of self in women who encounter abuse. Four major themes evolvedfrom the study: lack of relational authenticity. immobility, emptiness, and disconnection.

CONCLUSIONS: As a result of the study, more appropriate interventions directed to ward relational development can be actualized for women who encounter abuse.
Assertive Community Treatment of the Long-term Mentally Ill
Authors: Guy Sally
Published: January 2017

For several reasons including thefailures of deinstitutionalization, the inadequacy of community resources, and poor coordination among service agencies, the needs of people with long-term mental illness living in the community have not been adequately met. Yet recent changes in the mental health care treatment system have sustained the shift in the locus of mental health care from inpatient settings to the community. This article discusses the characteristics and needs ofpeople with long-term mental illness living in the community. Gaps in service are identified, and an innovative assertive community treatment approach to close some of those gaps is described. Suggestions are proposed for differentiating the role of the psychiatric nurse from other clinicians in assertive community treatment teams.
Compassionate, Caring Volunteers + Lonely Care Facility Patients = Conversation, Companionship, and Love
Authors: Bowers Joan Kinkead
Published: January 2017

The Visiting Nurse Association of the Midlands in Omaha, Nebraska, developed its patient advocate-visitation program in 1998. Since then, the program has changed, grown, and with the help of many compassionate and caring volunteers, affected the lives of countless care facility residents throughout the greater Omaha area. The volunteers have found that a person’s home is where the person resides, and home care, in the form of support, companionship, understanding, and love, can be given in any setting. Patient advocate-visitation volunteers are meeting the needs of lonely patients and turning care facility rooms into homes.
Six Steps toward Cultural Competence: A Clinician’s Guide
Authors: Narayan Mary Curry
Published: January 2017

In December 2000, the Office of Minority Health published the National Standards on Culturally and Linguistically Appropriate Services in Health Care (CLAS Standards), making cultural competence in home health clinical practice a critical competency. This article describes a six-step model clinicians—nurses or therapists—can apply to provide culturally competent care to home care patients.
Impact of the Number of Dermatologists on Dermatology Biomedical Research: A Canadian Study
Authors: Lanzini Rosilene Canzi , Fallen Robyn S. , Wismer Judy , Lima Hermenio C.
Published: January 2017

Background:

Fewer dermatologists than other clinical specialists are entering and being retained as physicians in the Canadian medical workforce. Studies suggest that dermatologist numbers may influence skin disease outcomes. No study has questioned whether the number of clinical dermatologists can influence academic productivity.

Objective:

To quantify the correlation of the number of dermatologists with biomedical scientific production in this field from 1996 to 2008 in Canada.

Methods:

Canadian dermatology biomedical scientific production from SCImago Journal & Country Rank (SJR) were merged with Canadian Medical Association (CMA) dermatologist demographic data. Linear regression analyses were used to model the relationships.

Results:

The low growth of dermatologist numbers by 8.16% in Canada from 1996 to 2008 correlates with a small increase in articles by 7.59% published in this subject area during this period. This has reduced the scientific importance of Canadian dermatology in the world.

Conclusion:

The number of dermatologists was a significant predictor of biomedical research production in the field of dermatology. This suggests that specialist availability may be one factor influencing dermatology research and publications.
Granuloma Pyogenicum as a Complication of Decorative Nose Piercing: Report of Eight Cases from Eastern India
Authors: Ghosh Sudip Kumar , Bandyopadhyay Debabrata
Published: January 2017

Background:

Body piercing has become a common fashion trend globally, irrespective of social classes and age groups. Almost no external organ in the human body has escaped piercing. Nose piercing is a fairly common practice all over the world. A number of local and systemic complications (both infectious and noninfectious) may follow nose piercing. Piercing by nonprofessional or unskilled persons, use of nonsterile piercing instruments, and poor standards of hygiene in the care of the puncture site are the most important factors accountable for such complications.

Objective and Conclusion:

We report here a case series of eight patients who presented with nasal granuloma pyogenicum following decorative nasal piercing to highlight a relatively rare but potentially serious complication of the procedure. The role of adopting appropriate sterile techniques for preventing such complication is emphasized.
Sister Mary Joseph's Nodule
Authors: Davar Sandra , Hanna Dominique
Published: January 2017

Background:

Sister Mary Joseph's nodule (SMJN) represents an unusual clinical feature of metastatic deposit at the umbilicus originating from an intra-abdominal malignancy.

Objective:

To outline the paucity of such a condition, review the associated pathologies, and demonstrate the importance of clinical and histopathologic correlation.

Methods:

Case report of a 75-year-old man with vesical and prostatic cancers treated 2 years prior to presenting with an umbilical lesion. Histopathologic and radiologic examinations were performed to confirm the clinical diagnosis.

Results:

Histopathology of the umbilical biopsy revealed a carcinoma of urothelial origin, but immunohistochemistry suggested a squamous cell carcinoma. Clinically, the lesion did not support a diagnosis of primary squamous cell carcinoma; in addition, the positron emission tomographic scan revealed a captation at the ureterovesical junction that was compatible with vesical cancer relapse.

Conclusion:

SMJN is a rare but typical cutaneous metastasis of internal malignancy, and its recognition is of great importance because it may be the first presenting sign in a patient with an unknown malignant disease.
Gastric Leiomyoma and Hyperplastic Polyposis Coli in a Patient with Multiple Cutaneous and Uterine Leiomyomatosis
Authors: Serra David , Amaro Pedro , Gonçalo Margarida , Silva Mário , Ferrando Barbara , Pasini Barbara , Figueiredo Américo
Published: January 2017

Background:

Cutaneous leiomyomatosis has been associated with multiple uterine myomas and, more recently, with germline heterozygous mutations of the FH gene and certain types of renal cancer. Despite the growing amount of knowledge concerning this genodermatosis, its clinical spectrum remains incompletely characterized.

Objective:

We report the observation of a patient with multiple cutaneous and uterine leiomyomatosis (MCUL) with unusual gastrointestinal manifestations.

Methods and Results:

A gastric leiomyoma was diagnosed on a 38-year-old female MCUL patient on endoscopy performed because of mild dyspepsia. Furthermore, routine colonoscopy disclosed hyperplastic polyposis. Genetic testing revealed a previously not reported mutation of the FH gene.

Conclusion:

Gastrointestinal lesions such as the present ones are frequently asymptomatic and probably underdiagnosed. As the phenotypical spectrum associated with mutations of the FH gene keeps expanding, clinicians should keep in mind that, besides renal cancer, other unexpected tumors could also arise in this setting.
Intralesional Methotrexate Treatment for Keratoacanthoma Tumors: A Retrospective Case Series
Authors: Aubut Nicolas , Alain Jimmy , Claveau Joël
Published: January 2017

Background:

Intralesional methotrexate (IL-MTX) is an effective treatment for keratoacanthoma.

Objective:

We sought to determine the response rates and adverse events in KA treated with intralesional methotrexate.

Methods:

All cases of KA treated with intralesional methotrexate at our institutions from 2001 to 2009 were systematically reviewed.

Results:

Forty-six cases of KA treated with IL-MTX were identified. A complete resolution was achieved in 74% of patients, requiring an average of 1.8 injection sessions, for a mean total dose of 10 mg. Adverse events did not occur.

Limitations:

The follow-up period was short, and there was no histologic confirmation of the initial diagnosis.

Conclusion:

IL-MTX is an effective and well-tolerated alternative to surgery for the treatment of KA.
Potential Role of Neurogenic Inflammatory Factors in the Pathogenesis of Vitiligo
Authors: Yu Richard , Huang Yuanshen , Zhang Xuejun , Zhou Youwen
Published: January 2017

Background:

Vitiligo is a highly complex multifactorial condition of the skin that has an unclear mechanism of pathogenesis.

Objective:

This review summarizes the role of various neurogenic inflammatory factors significantly upregulated in vitiligo.

Methods:

A literature review was conducted of all pertinent data regarding neuropeptides that are altered in vitiligo and their possible role in the destruction of melanocytes.

Results:

The close associations between the skin, immune system, and nervous system, along with specific changes demonstrated in vitiligo patients, support a pathogenic mechanism of vitiligo that involves neuroimmunologic factors, the release of which can be governed by mental stress.

Conclusion:

Neuropeptides and nerve growth factors are critical regulators of emotional response and may precipitate the onset and development of vitiligo in certain predisposed individuals. More studies are required to investigate whether a direct link exists between genetics, mental stress, and neurogenic factors in vitiligo.
Necrobiosis Lipoidica Diabeticorum in a Tattoo Site
Authors: Babin-Muise Dominique , Miller Robert , Murray Scott , Walsh Noreen
Published: January 2017

Background:

Trauma is an immediate triggering factor in the development of necrobiosis lipoidica diabeticorum (NLD). NLD has previously never been documented in a tattoo site.

Objective and Conclusion:

Here we report an otherwise healthy 35-year-old woman with an area of NLD located in a tattoo site. Initial injection with intralesional triamcinalone acetonide showed no benefit. Subsequent application of betamethasone valerate cream did not lead to improvement of the lesion.
Botanicals With Dermatologic Properties Derived From First Nations Healing: Part 2—Plants and Algae
Authors: Colantonio Sophia , Rivers Jason K.
Published: January 2017

Introduction:

Plants and algae have played a central role in the treatment of skin conditions in both traditional First Nations healing and in modern dermatology. The objective of this study was to examine the evidence supporting the dermatological use of seaweed, witch hazel, bearberry, and mayapple.

Methods:

Four plants and algae used in traditional First Nations treatments of skin disease were selected based on expert recommendations. Several databases were searched to identify relevant citations without language restrictions.

Results:

Seaweed has potential clinical use in the treatment of acne and wrinkles and may be incorporated into biofunctional textiles. Witch hazel is an effective and well-tolerated treatment of inflammation and diaper dermatitis. Bearberry leaves contain arbutin, a skin-lightening agent that is an alternative for the treatment of hyperpigmentation. Mayapple contains podophyllotoxin, a treatment for condyloma accuminata, molluscum contagiosum, and recalcitrant palmoplantar warts.

Discussion:

Common plants and algae are replete with bioactive agents that may have beneficial effects on the skin. Further research will open the door to new and innovative products in the future. Limitations of this study include that the scope of our study is limited to 4 plants and algae, a small sample of the breadth of plants used by First Nations for dermatological treatments.
A Rare Case of Oestrogen Dermatitis
Authors: Bourgeault Emilie , Bujold Janie , Doucet Marie-Eve
Published: January 2017

Background:

Oestrogen dermatitis is a rare disorder characterised by cyclical eruptions in association with a woman’s menstrual cycle.

Methods:

A 43-year-old woman with an 8-year history of cyclical inguinal dermatitis, with a negative patch test, was tested with intradermal progesterone and oestrogen.

Results:

Intradermal testing was positive for oestrogen only.

Conclusion:

In a female patient with cyclical dermatitis, it is important to consider oestrogen or progesterone dermatitis in the differential diagnosis.
Evaluation of the Efficacy of Cryosurgery in Patients With Sebaceous Hyperplasia of the Face
Authors: Ataş Hatice , Gönül Müzeyyen
Published: January 2017

Background:

Cryosurgery is an effective treatment for sebaceous hyperplasia, but there have been few clinical studies.

Objectives:

The aim of this study was to evaluate the efficacy and safety of cryosurgery in the treatment of sebaceous hyperplasia.

Methods:

Cryosurgery was performed 6 times, at 2-week intervals, with liquid nitrogen, and evaluated in 40 patients with 517 lesions ranging from 2 to 9 mm over the forehead, cheeks, and chin. All of the lesions were measured before and after the treatment.

Results:

The mean age of the participants was 54.7 ± 8.9 years, and the male/female ratio was 21/19 (1.1). The mean time of the disease duration was 4.2 ± 3.0 years. After 6 cooling cycles, an excellent response (76%-100%) was seen in 341 patients (65.9%), a very good response (51%-75%) was seen in 102 (19.7%), a good response (26%-50%) was seen in 57 (11.1%), a poor response (1%-25%) was seen in 15 (2.9%), and no response (0%) was seen in 2 (0.4%). Age ( P = .004) and sex ( P < .0001) were independent predictors of an excellent response. The excellent response rates were 71.4% for males, 61.8% for females, 70.4% for ages older than 55 years, and 61.8% for ages younger than 55 years. Temporary hyperpigmentation was found in 5 lesions (0.96%), and recurrence was not seen at the 4-month follow-up.

Conclusions:

The well-aimed and controlled used of cryosurgery is an effective method for treating significant cosmetic disfigurement in patients with sebaceous hyperplasia. It is a low-cost therapy without scarring, hypopigmentation, or recurrence.
Review of Atopic Dermatitis and Topical Therapies
Authors: Mayba Julia N. , Gooderham Melinda J.
Published: January 2017

Atopic dermatitis is one of the most common skin disorders in the developed world, affecting up to 20% of children and 1% to 3% of adults. This review concisely explains the pathophysiology and epidemiology of atopic dermatitis, as well as potential challenges facing its successful treatment. Furthermore, mainstay topical treatment modalities are evaluated, such as emollients, topical corticosteroids, and topical calcineurin inhibitors. The use of topical corticosteroids and topical calcineurin inhibitors in combination is discussed, as studies have indicated encouraging results. The proactive use of topical corticosteroids and topical calcineurin inhibitors is also investigated, in order to bring attention to a new possibility in long-term management of atopic dermatitis. Last, new and upcoming topical medications are described, including Janus kinase inhibitors, phosphodiesterase-4 inhibitors, and benvitimod. Although topical corticosteroids and topical calcineurin inhibitors can be very effective in the treatment of atopic dermatitis, it is important that practitioners are aware of mechanistically unique and new treatments for patients for whom more traditional topical therapies have failed. Overall, this review article hopes to serve as a comprehensive overview of currently available topical treatments for atopic dermatitis, while shedding light on new treatments coming in the future.
Does General Practitioner Gatekeeping Curb Health Care Expenditure?
Authors: Delnoij Diana , Van Merode Godefridus , Paulus Aggie , Groenewegen Peter
Published: January 2017

Objectives:

It is generally assumed that health care systems in which specialist and hospital care is only accessible after referral by a general practitioner (GP) have lower total health care costs. In this study, the following questions were addressed: do health care systems with GPs acting as gatekeepers to specialized care have lower health care expenditure than those with directly accessible specialist care? Does health care expenditure increase more rapidly in countries without a referral system than in those with the GP acting as a gatekeeper?

Methods:

Multiple regression analyses on total and ambulatory health care expenditure in 18 OECD countries.

Results:

Analyses showed only one statistically significant effect ( P< 0.05) in countries with gatekeeping GPs: ambulatory care expenditure has increased more slowly than in non-gatekeeping systems. No significant effects of gatekeeping were found on the level of ambulatory care costs, or on the level or growth of total health care expenditure. As in earlier studies, the most important factor influencing aggregate health care costs and their growth is gross national product (GNP), followed by the share of public funding. Relationships that exist at a micro level (such as lower costs with a gatekeeping primary care doctor) did not show up in aggregate data at a macro level.

Conclusions:

Gatekeeping systems appear to be better able to contain ambulatory care expenditure. More research is necessary to understand micro level mechanisms and to distinguish the effects of gatekeeping from other structural aspects of health care systems.
Principal—Agent Relationships in General Practice: The First Wave of English Personal Medical Services Pilot Contracts
Authors: Sheaff Rod , Lloyd-Kendall Andrew
Published: January 2017

Objectives:

To investigate how far English National Health Service (NHS) Personal Medical Services (PMS) contracts embody a principal—agent relationship between health authorities (HAs) and primary health care providers, especially, but not exclusively, general practices involved in the first wave (1998) of PMS pilot projects; and to consider the implications for relational and classical theories of contract.

Methods:

Content analysis of 71 first-wave PMS contracts.

Results:

Most PMS contracts reflect current English NHS policy priorities, but few institute mechanisms to ensure that providers realise these objectives. Although PMS contracts have some classical characteristics, relational characteristics are more evident. Some characteristics match neither the classical nor the relational model.

Conclusions:

First-wave PMS contracts do not appear to embody a strong principal—agent relationship between HAs and primary health care providers. This finding offers little support for the relevance of classical theories of contract, but also implies that relational theories of contract need to be revised for quasi-market settings. Future PMS contracts will need to focus more on evidence-based processes of primary care, health outputs and patient satisfaction and less upon service inputs. PMS contracts will also need to be longer-term contracts in order to promote the ‘institutional embedding’ of independent general practice in the wider management systems of the NHS.
Clinicians' Attitudes to Recruitment to Randomised Trials in Cancer Care: A Qualitative Study
Authors: Langley Carole , Gray Selena , Selley Sara , Bowie Cameron , Price Chris
Published: January 2017

Objectives:

To explore attitudes to and problems experienced with recruitment into randomised trials in cancer care.

Methods:

In-depth semi-structured interviews with a purposive sample of 20 hospital clinicians in the South West of England identified from 192 participants in a larger postal survey. Interviews were recorded on audiotape and fully transcribed. Data were analysed by comparing transcripts and describing emergent themes.

Results:

Clinicians do not always find it easy to identify key randomised trials in their area of interest. Even when they identify those trials in which they would like to participate, they are not always able to recruit patients. Although recruitment can be hindered by the time and administration involved and the resources needed, the attitudes of clinicians to research in general, the design of randomised trials, clinicians' concerns regarding individual patients and patients' preferences for different treatments also present major barriers. Other factors of concern include the imposition of strict eligibility criteria and the expense and complexity of monitoring and follow-up.

Conclusion:

Barriers to recruitment depend on the clinicians' individual situations and on a complex combination of factors. Action is needed to promote awareness of randomised trials under way, to ensure that trials address issues of importance, are acceptable to patients and clinicians, and that practical support is provided for participating centres.
Priority-Setting in New Zealand: Translating Principles into Practice
Authors: Ashton Toni , Cumming Jackie , Devlin Nancy
Published: January 2017

In May 1998 the New Zealand Health Funding Authority released a discussion paper which proposed a principles-based approach to setting purchasing priorities that incorporates the economic methods of programme budgeting and marginal analysis, and cost—utility analysis. The principles upon which the process was to be based are effectiveness, cost, equity of health outcomes, Maori health and acceptability. This essay describes and critiques issues associated with translating the principles into practice, most particularly the proposed methods for evaluating the effectiveness and measuring the cost of services. It is argued that the proposals make an important contribution towards the development of a method for prioritising services which challenges our thinking about those services and their goals, and which is systematic, explicit, and transparent. The shift towards ‘thinking at the margin’ and systematically reviewing the value for money of competing claims on resources is likely to improve the quality of decision-making compared with the status quo. This does not imply that prioritisation can, or should, be undertaken by means of any simple formula. Any prioritisation process should always be guided by informed judgement. The approach is more appropriate for some services than for others. Key methodological issues that need further consideration include the choice of instrument for measuring health gains, the identification of marginal services, how to combine qualitative and quantitative information, and how to ensure consistency across different levels of decision-making.
Who are the High Hospital Users? A Canadian Case Study
Authors: Roos Noralou , Burchill Charles , Carriere Keumhee
Published: January 2017

Objectives:

Researchers have taken two different approaches to understanding high use of hospital services, one focusing on the large proportion of services used by a small minority and a second focusing on the poor health status and high hospital use of the poor. This work attempts to bridge these two widely researched approaches to understanding health care use.

Methods:

Administrative data from Winnipeg, Manitoba covering all hospitalizations in 1995 were combined with public use Census measures of socio-economic status (neighbourhood household income). High users were defined as the 1% of the population who spent the most days in hospital in 1995 ( n = 6487 hospital users out of population of 648 715 including non-users).

Results:

One per cent of the Winnipeg population consumed 69% of the hospital days in 1995. Thirty-one per cent of the highest users were among the 20% of residents of neighbourhoods with the lowest household incomes, and 10% of the highest users were among the 20% from neighbourhoods with the highest household incomes. However, on most other dimensions, including gender, age, average days in hospital, average admissions, percentage who died in hospital and diagnostic reasons for being hospitalized, the similarities between high users, regardless of their socio-economic group, were striking.

Conclusions:

The lower the socio-economic status, the more likely an individual is to make high demands on hospitals. However, patterns of use as well as the diseases and accidents that produce high use among residents of low income neighbourhoods are not much different from those that produce high use among residents of high income neighbourhoods.
What Predicts Patients' Interest in the Internet as a Health Resource in Primary Care in England?
Authors: Mead Nicola , Varnam Robert , Rogers Anne , Roland Martin
Published: January 2017

Objectives:

To identify what factors predict patients' interest in using Internet health information in the light of poor uptake of a free, guided Internet service in one inner-city general practice.

Methods:

Questionnaires were administered over a five-day period to consecutive adult patients attending two Manchester general practices: An inner-city practice serving a relatively deprived patient population where the free Internet service had previously been available, and a suburban practice serving a relatively affluent population. Data were analysed using multiple regression to identify predictors of self-reported interest in using the Internet for health information.

Results:

A total of 753 (74%) patients completed the questionnaire although analyses were restricted to 660 (65%) cases. Independent predictors of patient-reported interest in getting health information from the Internet were (in order of relative ‘importance’): Positive outcome expectancy (i.e. the patient's strength of belief that it would enable them to deal better with their health); previous use of health websites; positive ‘self-efficacy’ (i.e. patients' confidence in their ability to use the technology); higher education; a positive attitude to getting health information from alternative sources; social deprivation; and having school-age children living at home. Level of Internet access was an important determinant of self-efficacy, but home access was the key predictor of outcome expectancy and past use of ‘e-health’.

Conclusions:

Access, demographics and, particularly, motivational factors all influence patients' interest in the Internet as a health resource. Proposals to encourage more widespread use of digital health information need to take account of this complexity and not deal with access issues alone.
Annual Appraisal and Liege Homage: Why the British NHS is Fundamentally a Feudal Organisation
Authors: Tyler Len , Evans Ann
Published: January 2017

A study of the past can help us understand present-day management structures. Strong parallels can be seen between the present-day British National Health Service (NHS) and English feudal society in the early Middle Ages. Both systems are hierarchical, both show limited mobility between layers in the hierarchies and in both there is a strong element of central control coexisting with significant day-to-day delegation of responsibility. Ceremony plays a key role in relationships, such as through the swearing of liege homage in feudal society and through formal assessment and appraisal in the modern NHS. Although the NHS clearly does not show parallels for every element of feudal society, it is possible to draw practical lessons from the comparison, particularly relating to the ownership of problems, team-working and appraisal.
Micro-Level Analysis of Distributional Changes in Health Care Financing in Finland
Authors: Klavus Jan , Häkkinen Unto
Published: January 2017

Objectives:

In the early 1990s the Finnish economy suffered a severe recession at the same time as health care reforms were taking place. This study examines the effects of these changes on the distribution of contributions to health care financing in relation to household income. Explanations for changes in various indicators of health care expenditure and use during that time are offered.

Method:

The analysis is based partly on actual income data and partly on simulated data from the base year (1990). It employs methods that allow the estimation of confidence intervals for inequality indices (the Gini coefficient and Kakwani's progressivity index).

Results:

In spite of the substantial decrease in real incomes during the recession, the distribution of income remained almost unaltered. The share of total health care funding derived from poorer households increased somewhat, due purely to structural changes. The financial plight of the public sector led to the share of total funding from progressive income taxes to decrease, while regressive indirect taxes and direct payments by households contributed more.

Conclusions:

It seems that, aside from an increased financing burden on poorer households, Finland's health care system has withstood the tremendous changes of the early 1990s fairly well. This is largely attributable to the features of the tax-financed health care system, which apportions the effects of financial and functional disturbances equitably.
League Tables for Performance Improvement in Health Care
Authors: Nutley Sandra , Smith Peter C.
Published: January 2017

Objectives:

Increasingly health care performance data are being disseminated in the form of ‘league tables' of health care providers, with the implication that such publication helps purchasers select the better providers, and spurs providers into improvements. This paper examines progress to date.

Methods:

Three stages of the league table process are considered: measurement, analysis and action.

Results:

A wide range of measurement schemes are now in place, although the emphasis has been on process variables and mortality as a measure of outcome. Several analytical techniques have been deployed to help users make sense of league tables, and to help determine the causes of variations in reported performance. The weakest aspect of current methods relates to the use to which such analysis is put.

Conclusions:

A haphazard approach to using league table data exists, with few reports on the impact of publication. A variety of directions for future research into the use of performance data are needed.
Determinants of Ambulatory Physician Utilization among Adults with Chronic Diseases in Quebec
Authors: Bads Enis , Champagne François , Rivard Michéle
Published: January 2017

Objectives:

To test the explanatory power of a model of ambulatory service use and to determine the relative roles of the main determinants of physician utilization for two chronic medical conditions in adults in Quebec.

Methods:

A behavioral model based on Andersen's model was developed and tested by linking two databases: the Quebec health survey as regards patient characteristics, and the Quebec health insurance board data on physician characteristics and service use. Path analysis was used for data analysis.

Results:

The model explained a little less than 20% of the variation in service use. The number of hospitalizations, physician's specialty and perceived health were the most important predictors of the volume of visits.

Conclusion:

Further specification of utilization, relating it to a particular medical condition, does not necessarily lead to an increase in the explanatory power of the model. We recommend that future research should put more emphasis on provider-related determinants rather than focusing on the type and purpose of utilization.
The Limits of Leadership: Opinion Leaders in General Practice
Authors: Flottorp Signe , Oxman Andrew , Bjørndal Arild
Published: January 2017

Objective:

To explore the importance and characteristics of opinion leaders in general practice, particularly in relationship to the use of laboratory tests.

Design:

Focus group discussions and a mailed survey.

Subjects:

Five focus groups ( n = 29 participants) in four different municipalities and a random sample of 85 general practitioners (GPs) in Norway.

Results:

While Norwegian GPs recognised colleagues who were influential in determining how they practised, they found it difficult to identify opinion leaders specifically with respect to the use of laboratory tests. Opinion leaders were thought to be less important in influencing the use of laboratory tests than continuing medical education activities and practice guidelines, but more important than industry, patients or personal financial interests. Norwegian GPs recognised and characterised opinion leaders in much the same way as physicians in the USA. Influential colleagues were characterised as being good conveyers of information and willing to take time, as well as being up-to-date and having a high level of clinical expertise. GPs expressed a negative attitude towards ‘superspecialists’ who give advice without knowing the epidemiology of general practice, people who are arrogant and people who do not show respect towards GPs.

Conclusions:

The potential to identify and use opinion leaders to improve the use of laboratory tests by GPs in Norway appears to be limited.
Shifting Services from Secondary to Primary Care: Stakeholders' Views of the Barriers
Authors: O'Cathain Alicia , Musson Gill , Munro James
Published: January 2017

Objectives:

To identify the barriers to shifting services from secondary to primary care perceived by the involved stakeholders.

Methods:

Forty-five semi-structured interviews with stakeholders from primary care, acute and community hospitals, purchasers (health authorities) and other agencies involved in two contrasting initiatives to shift services.

Results:

Stakeholders perceived similar barriers in the two initiatives: disinvesting from existing providers; lack of information on activity and costs; uncertainty over the quality of the proposed alternative service; concern about an increasing workload in primary care; diversity of views within primary care; difficulties in communication between the many agencies involved; and lack of leadership by purchasers.

Conclusions:

Service shifts which involve disinvestment from existing providers and collaboration between agencies with different views and interests will inevitably face a range of barriers. Attempts to shift services by disinvesting from secondary care are likely to encounter the greatest difficulties. Attempts to shift without concomitant disinvestment may also be slow because of the difficulties of multi-agency collaboration. Frustration will be reduced if those involved have a realistic understanding of the difficulties rather than being surprised and overwhelmed by them.
Commissioning Health Services Research: An Iterative Method
Authors: Lilford Richard , Jecock Rowena , Shaw Howard , Chard Jiri , Morrison Brian
Published: January 2017

The standard linear method of commissioning research involves many stages, some lengthy. While assessment criteria are usually explicit, their weighting and interaction are not. Output is assessed on completion. This method is suitable where the research question is clear-cut. However, it has drawbacks when the research question and the form and scope of the research are not clear at the outset, as is often the case with research on the delivery and organisation of services. Also, it does not encourage potential users of the research to develop a sense of ownership. An alternative method is proposed by which the scope, form and content of research are not specified in advance but are developed iteratively. A programme director, advised by a group of potential users and research commissioners, has devolved authority to commit funding for the stages of the work as it unfolds, predicated on evolving need. There are foreseeable but avoidable risks of the group over-identifying with the researchers, of research management becoming cumbersome, and of unproductive friction between research groups when they are required to work together. The iterative method, being new and untried, is itself an organisational change requiring evaluation. However, from our local experience, it provides for productive dialogue between research commissioners, researchers and potential users.