bluuebunny/crossref_metadata_2025 huggingface dataset:
Overexpression of vitamin D receptor indicates a good prognosis for cholangiocarcinoma
Authors: Seubwai Wunchana , Wongkham Chaisiri , Puapairoj Anucha , Khuntikeo Narong , Wongkham Sopit
Published: May 2007

BACKGROUND.

Up‐regulation of vitamin D receptor (VDR) expression has been shown in several tumors and is thought to represent an important endogenous response to tumor progression. The authors aimed to verify the expression of VDR and its clinical significance in histologically proven cholangiocarcinoma (CCA).

METHODS.

The antiproliferative activity of vitamin D3 on CCA cell lines was explored. The immunohistochemistry of 111 paraffin‐embedded CCA tissues showed that VDR expression gradually increased during CCA development. Normal bile duct epithelium rarely expresses VDR, whereas more than 74% of CCA tissues showed positive VDR staining, of which 40% were high. Approximately 80%–90%of CCA patients with papillary and well differentiated adenocarcinomas had positive VDR expression in tumor tissues, whereas 39% positive VDR expression was found in those with poorly differentiated CCAs (P < .001).

RESULTS.

Expression of VDR was shown to be compatible with an overall favorable prognosis for CCA. Treatment with 1,25(OH)2D3, an active metabolite of vitamin D3, in the CCA cell lines with high expression of VDR significantly reduced cell proliferation in a dose‐dependent manner. The effect was not demonstrated in the CCA cell lines that had lower VDR expression.

CONCLUSIONS.

These data indicated an active role for VDR in mediating the antiproliferative effects of 1,25(OH)2D3 in CCA cell lines. VDR expression may constitute an important prerequisite for using vitamin D and/or its analogs in the treatment of CCA. Investigation of a mechanism by which VDR and its ligand mediate these processes is needed to provide the basis for the potential use of this hormone and its derivatives in the prevention and treatment of CCA. Cancer 2007. © 2007 American Cancer Society.
Need for closure and competition in intergroup conflicts: experimental evidence for the mitigating effect of accessible conflict‐schemas
Authors: de Zavala Agnieszka Golec , Federico Christopher M. , Cisłak Aleksandra , Sigger Jonathan
Published: May 2007

Three experimental studies demonstrate that momentarily accessible conflict‐schemas moderate the relationship between need for closure and conflict‐strategy preferences, with the relationship between a high need for closure and increased competitiveness reduced to non‐significance when a cooperative conflict‐schema is made salient but strengthened when a hostile one is activated. Study 1 manipulated the accessibility of competitive versus cooperative conflict‐schemas using different descriptions of a contemporary political conflict, while Studies 2 and 3 manipulated conflict‐schema accessibility using primes embedded in an ostensibly unrelated lexical decision task. Together, the present studies provide a strong pattern of experimental support for the moderating effect of conflict‐schema accessibility suggested by earlier correlational studies. The implications for conflict reduction are discussed. Copyright © 2007 John Wiley & Sons, Ltd.
Optimization of a pressurized liquid junction nanoelectrospray interface between CE and MS for reliable proteomic analysis
Authors: Kusý Petr , Klepárník Karel , Aturki Zeineb , Fanali Salvatore , Foret František
Published: May 2007

A pressurized liquid junction nanoelectrospray interface was designed and optimized for reliable on‐line CE‐MS coupling. The system was constructed as an integrated device for highly sensitive and selective analyses of proteins and peptides with the separation and spray capillaries fixed in a pressurized spray liquid reservoir equipped with the electrode for connection of the electrospray potential. The electrode chamber on the injection side of the separation capillary and the spray liquid reservoir were pneumatically connected by a Teflon tube filled with pressurized nitrogen. This arrangement provided precisely counterbalanced pressures at the inlet and outlet of the separation capillary. The pressure control system was driven by an electrically operated valve and maintained the optimum flow rate for the electrospray stability. All parts of the interface being in contact with the CEBGE, spray liquid and/or sample were made of glass or Teflon. The use of these materials minimized the electrospray chemical noise often caused by plastic softeners or material degradation. During optimization, the transfer of the separated zones between the separation and electrospray capillaries was monitored by UV absorbance and contactless conductivity detectors placed at the outlet of the separation capillary and inlet of the electrospray tip, respectively. This arrangement allowed independent monitoring of the effects of pressure, CE voltage and geometry of the liquid junction on the spreading and dilution of the separated zones after passage through the interface.
An evaluation of parsimony for microbial risk assessment models
Authors: Soller Jeffrey A. , Eisenberg Joseph N. S.
Published: May 2007

Microbial risk assessment (MRA) is a process that evaluates the likelihood of adverse human health effects following exposure to a medium in which pathogens are present. Several different classes of models are available to quantitatively characterize risks to human health from exposure to pathogens. Herein, we consider the question of parsimony for specific realizations of representative static and dynamic MRA models and identify conditions under which the more complex dynamic model provides sufficient additional insight to justify the added modeling complexity. To address this question, a standard static individual‐level risk model is compared to a deterministic dynamic population‐level model that explicitly includes secondary transmission and immunity processes. Exposure parameters are based on a scenario defined by human exposure to pathogens in reclaimed water. A sensitivity analysis is implemented to identify conditions under which static and dynamic models yield substantially different results. Under low risk conditions, defined by a combination of exposure levels and infectivity of the pathogen, the simpler static model provides satisfactory risk estimates. The approach presented here provides a basis for model selection for a broad range of MRA applications. Copyright © 2007 John Wiley & Sons, Ltd.
Sequential haplotype scan methods for association analysis
Authors: Yu Zhaoxia , Schaid Daniel J.
Published: May 2007

Multi‐locus association analyses, including haplotype‐based analyses, can sometimes provide greater power than single‐locus analyses for detecting disease susceptibility loci. This potential gain, however, can be compromised by the large number of degrees of freedom caused by irrelevant markers. Exhaustive search for the optimal set of markers might be possible for a small number of markers, yet it is computationally inefficient. In this paper, we present a sequential haplotype scan method to search for combinations of adjacent markers that are jointly associated with disease status. When evaluating each marker, we add markers close to it in a sequential manner: a marker is added if its contribution to the haplotype association with disease is warranted, conditional on current haplotypes. This conditional evaluation is based on the well‐known Mantel‐Haenszel statistic. We propose two permutation based methods to evaluate the growing haplotypes: a haplotype method for the combined markers, and a summary method that sums conditional statistics. We compared our proposed methods, the single‐locus method, and a sliding window method using simulated data. We also applied our sequential haplotype scan algorithm to experimental data for CYP2D6. The results indicate that the sequential scan procedure can identify a set of adjacent markers whose haplotypes might have strong genetic effects or be in linkage disequilibrium with disease predisposing variants. As a result, our methods can achieve greater power than the single‐locus method, yet is much more computationally efficient than sliding window methods.Genet. Epidemiol. 2007. © 2007 Wiley‐Liss, Inc.
A dictionary model for haplotyping, genotype calling, and association testing
Authors: Ayers Kristin L. , Sabatti Chiara , Lange Kenneth
Published: May 2007

We propose a new method for haplotyping, genotype calling, and association testing based on a dictionary model for haplotypes. In this framework, a haplotype arises as a concatenation of conserved haplotype segments, drawn from a predefined dictionary according to segment specific probabilities. The observed data consist of unphased multimarker genotypes gathered on a random sample of unrelated individuals. These genotypes are subject to mutation, genotyping errors, and missing data. The true pair of haplotypes corresponding to a person's multimarker genotype is reconstructed using a Markov chain that visits haplotype pairs according to their posterior probabilities. Our implementation of the chain alternates Gibbs steps, which rearrange the phase of a single marker, and Metropolis steps, which swap maternal and paternal haplotypes from a given maker onward. Output of the chain include the most likely haplotype pairs, the most likely genotypes at each marker, and the expected number of occurrences of each haplotype segment. Reconstruction accuracy is comparable to that achieved by the best existing algorithms. More importantly, the dictionary model yields expected counts of conserved haplotype segments. These imputed counts can serve as genetic predictors in association studies, as we illustrate by examples on cystic fibrosis, Friedreich's ataxia, and angiotensin‐I converting enzyme levels. Genet. Epidemiol. © 2007 Wiley‐Liss, Inc.
Caspase‐3 activation in astrocytes following postnatal excitotoxic damage correlates with cytoskeletal remodeling but not with cell death or proliferation
Authors: Acarin Laia , Villapol Sonia , Faiz Maryam , Rohn Troy T. , Castellano Bernardo , González Berta
Published: May 2007

Caspase‐3 has classically been defined as the main executioner of programmed cell death. However, recent data supports the participation of this protease in non‐apoptotic cellular events including cell proliferation, cell cycle regulation, and cellular differentiation. In this study, astroglial cleavage of caspase‐3 was analyzed following excitotoxic damage in postnatal rats to determine if its presence is associated with apoptotic cell death, cell proliferation, or cytoskeletal remodeling. A well‐characterized in vivo model of excitotoxicity was studied, where damage was induced by intracortical injection of N‐methyl‐D‐asparate (NMDA) in postnatal day 9 rats. Our results demonstrate that cleaved caspase‐3 was mainly observed in the nucleus of activated astrocytes in the lesioned hemisphere as early as 4 h postlesion and persisted until the glial scar was formed at 7–14 days, and it was not associated with TUNEL labeling. Caspase‐3 enzymatic activity was detected at 10 h and 1 day postlesion in astrocytes, and co‐localized with caspase‐cleaved fragments of glial fibrillary acidic protein (CCP‐GFAP). However, at longer survival times, when astroglial hypertrophy was observed, astroglial caspase‐3 did not generally correlate with GFAP cleavage, but instead was associated with de novo expression of vimentin. Moreover, astroglial caspase‐3 cleavage was not associated with BrdU incorporation. These results provide further evidence for a nontraditional role of caspases in cellular function that is independent of cell death and suggest that caspase activation is important for astroglial cytoskeleton remodeling following cellular injury. © 2007 Wiley‐Liss, Inc.
Predicting 6‐week treatment response to escitalopram pharmacotherapy in late‐life major depressive disorder
Authors: Saghafi Ramin , Brown Charlotte , Butters Meryl A. , Cyranowski Jill , Dew Mary Amanda , Frank Ellen , Gildengers Ariel , Karp Jordan F. , Lenze Eric J. , Lotrich Francis , Martire Lynn , Mazumdar Sati , Miller Mark D. , Mulsant Benoit H. , Weber Elizabeth , Whyte Ellen , Morse Jennifer , Stack Jacqueline , Houck Patricia R. , Bensasi Salem , Reynolds Charles F.
Published: May 2007

Objective

Approximately half of older patients treated for major depressive disorder (MDD) do not achieve symptomatic remission and functional recovery with first‐line pharmacotherapy. This study aims to characterize sociodemographic, clinical, and neuropsychologic correlates of full, partial, and non‐response to escitalopram monotherapy of unipolar MDD in later life.

Methods

One hundred and seventy‐five patients aged 60 and older were assessed at baseline on demographic variables, depression severity, hopelessness, anxiety, cognitive functioning, co‐existing medical illness burden, social support, and quality of life (disability). Subjects received 10 mg/d of open‐label escitalopram and were divided into full (n = 55; 31%), partial (n = 75; 42.9%), and non‐responder (n = 45; 25.7%) groups based on Hamilton depression scores at week 6. Univariate followed by multivariate analyses tested for differences between the three groups.

Results

Non‐responders to treatment were found to be more severely depressed and anxious at baseline than both full and partial responders, more disabled, and with lower self‐esteem than full responders. In general partial responders resembled full responders more than they resembled non‐responders. In multivariate models, more severe anxiety symptoms (both psychological and somatic) and lower self‐esteem predicted worse response status at 6 weeks.

Conclusion

Among treatment‐seeking elderly persons with MDD, higher anxiety symptoms and lower self‐esteem predict poorer response after six weeks of escitalopram treatment. Copyright © 2007 John Wiley & Sons, Ltd.
Public attitudes to life‐sustaining treatments and euthanasia in dementia
Authors: Williams Nia , Dunford Charlotte , Knowles Alice , Warner James
Published: May 2007

Background

Issues surrounding end of life care, such as how aggressively to treat life threatening medical conditions in patients with dementia and when, if ever, to withhold or withdraw treatment require further scrutiny and debate.

Methods

We conducted a cross‐sectional survey to elicit the views of the general public on euthanasia and life‐sustaining treatments in the face of dementia.

Results

Seven hundred and twenty‐five members of the general public completed this questionnaire throughout London and the South East. In the face of severe dementia, less than 40% of respondents would wish to be resuscitated after a heart attack, nearly three‐quarters wanted to be allowed to die passively and almost 60% agreed with physician assisted suicide. Respondents were more likely to be in favour of life‐sustaining treatments for their partner than for themselves and the opposite was true regarding euthanasia. White respondents were significantly more likely to refuse life‐sustaining treatment and to agree to euthanasia compared with black and Asian respondents.

Conclusion

Our survey suggests that a large proportion of the UK general public do not wish for life‐sustaining treatments if they were to become demented and the majority agreed with various forms of euthanasia. Copyright © 2007 John Wiley & Sons, Ltd.
Obstetric care in the Netherlands: Manpower substitution and differential costs
Authors: Butter Irene , Lapre Ruud
Published: May 2007

Trends in the Netherlands show an expanded role for obstetricians in hospital‐based prenatal and natal care, as well as a shift in postnatal care away from hospitals to domiciliary care. While general practitioners attend a steadily declining share of total births, midwives continue to play a central role in supporting over 40 per cent of all births and in attending nearly two thirds of all home births, which, in the Netherlands, is the preferred option for more than a third of childbearing women. As shown in the figures, shifts of births into hospitals and of postnatal care out of hospitals produce opposite effects on obstetric expenditures. Cost differences are primarily associated with variation in location of care, and only secondarily with variation in provider of care, underscoring the importance of contrasting styles of obstetric management and their influence on costs. In the context of these observed transitions, the increasing popularity of policlinical deliveries constitutes a pivotal force whose impact to date appears to have been neglected by planners and health care decision makers.
Financing health care in the Sudan: Some recent experiments in the central region
Authors: Bekele Abraham , Lewis Maureen A.
Published: May 2007

The macroeconomic difficulties facing the developing countries are having a direct impact on these countries' public health programs. Reduced budgets and rising demands for health care are forcing health ministries to either cut back on already inadequate health care services or identify alternative sources of revenue. This article describes and analyzes a set of experiments designed and implemented by the Sudan's Central Province that have effectively raised the operating budget of the regional health ministry. The seven experiments encompass imposition of fees, cost containment efforts, and local taxes earmarked for health. Together, the revenue generating efforts have improved the efficiency of service delivery, ensured more efficient resource allocation, raised much needed revenue for the health system, and honored the government's commitment to make free health care available to the Sudanese population.
Reimbursement policy of hospitals in the Federal Republic of Germany
Authors: Altenstetter Christa
Published: May 2007

The factors that have contributed to an overhaul of German hospital policy in the last 12 months are both numerous and highly interrelated. Rising health expenditures and inflexible mechanisms for implementing hospital policy are major culprits, as are the considerably changed political and economic circumstances over the last 15 years.

Although this overhaul does embody some changes in the direction of German health care policy, they can best be understood as a further manifestation of the continuity that has characterized policy in this area for the past 100 years; a continuity rooted in the widely shared belief that disease, whatever its nature, is beyond the control of individuals.

The key to cost containment is considered to lie in the reduction of the average length of stay and in the better utilization of hospital facilities. Payment remains directly related neither to specific diagnoses of individual patients nor to occupancy rates in individual departments, which vary greatly across disciplines and specialities.

In the era that is unfolding, one political phenomenon requires close watching in the future: policy coalitions at the Land‐level will become even more important as prime movers than they have been in the past.

Demands for Strukturreform are a regular feature of many governmental systems. Yet the capacity of political bodies—whether ministries or parliaments—is severely limited by the distribution of power and control over resources and by the political dynamics which they generate. In the FRG, major reforms will not take place until after the 1987 federal elections, and it is essential to remember that the realms of campaign rhetoric and of policy choice and implementation are governed by entirely different sets of rules and constraints.
Same‐day surgery: Management issues and future growth
Authors: Westman John
Published: May 2007

Policy makers in all countries are searching for cost‐effective, quality health care. In the realm of surgical care, one response to modern cost and quality pressures is same‐day surgery. This article discusses three aspects of same‐day surgery programs: key management issues; analysis of competitiveness; and, the growth potential of same‐day surgery.

Today's managers of same‐day surgery programs are most concerned with issues related to their customers, be they physicians, insurers, or patients. Indeed, program managers identify market research, program development, and patient, physician, and facility management as areas critical to success.

An exploratory survey carried out of ten same‐day centers indicates that programs must excel in two areas to succeed. First, they must develop efficient and appropriate operations. Second, they must communicate aspects of these operations to different customers, realizing that each customer type is interested in different aspects of the program. This article provides a framework for the analysis of customer interests. It also suggests that surgery centers satisfy customer preferences rather better than do hospital outpatient programs.

Same‐day surgery will increase. Uncertainty lies in how quickly and in what form such activities in hospitals and centers will develop. Countries will likely experience different growth patterns, according to the relative power of factors affecting both the supply and demand of same‐day surgery.
Medical technology and health expenditure: An economic review and a proposal
Authors: Doessel Darrel
Published: May 2007

This paper is an evaluative survey of the economic literature on the relationship between technology and/or innovation and health expenditures. Various types of analysis viz. econometric modelling; three residual approaches; the cost‐of‐illness approach; and the literature on supplier interests are contrasted, and the results presented. The paper concludes with a discussion of the policy and planning implications, and a simple, and conventional, proposal is made that could unambiguously determine this relationship in the case of process innovations.
Physician autonomy in the Federal Republic of Germany, Great Britain and The United States
Authors: Schulz Rockwell , Harrison Stephen
Published: May 2007

The concepts of ‘professionalism’ (including autonomy) and ‘management’ (involving the control of others) are logically opposed; but, in the field of health care, physicians and managers have largely co‐existed without such opposition. International pressures for cost containment, however, now raise questions about the future nature of physician autonomy. This paper attempts, firstly, to conceptualize the nature of clinical autonomy as a number of independent components; secondly, to describe the nature of such autonomy in three countries in terms of these components; and, thirdly, to identify related questions for future research.
Information systems and physician practice patterns: England and America compared
Authors: Martin Anne L.
Published: May 2007

This paper discusses the opportunity for hospital management to make greater use of comparative data on physician productivity. We report findings from a study on utilization information provided to physicians in 19 US and British hospitals. Most doctors reported that they did not receive information comparing their own use of resources with that of their peers. However, our survey found that a significant majority of doctors want more information and find it useful; but, that hospital managers perceive doctors as being uninterested in such information. While there are wide variations between the two countries and between their hospitals in data collection and information systems, most hospitals surveyed could make better use of utilization information to influence physician practice patterns.
Community financing of drugs in sub‐Saharan Africa
Authors: Carrin Guy
Published: May 2007

‘Health for all by the year 2000’ is unlikely to be achieved in a number of Third World countries, including those in Sub‐Saharan Africa, if reliance is placed solely on the public health budget. This article looks at a range of alternative and additional sources of revenue and, in particular, at the scope for community financing of drugs. Developments in the region are reviewed for their insights into the strengths and weaknesses of each financing scheme; and, as a guide to shaping policies that make an appropriate choice of method of health care financing.
Health service financing in Poland
Authors: Tymowska Katarzyna
Published: May 2007

The right to a free health service is identified as one of the founding rules of socialism; yet other sources of funding, both public and private, should not be neglected. This article reviews the major sources of financing health services in Poland. In particular, a description is made of the size and composition of funding from non‐governmental sources including: quasi‐budget funds, other funds, and out‐of‐pocket payments; and some proposals are made for change. Further work is needed in developing the criteria by which policy choices can be made, and in developing the information base; at the same time, political and social criteria will still be very important, not least on the issue of user charges.
Mortality and morbidity transition in Kuwait: The role of health and development policies
Authors: Shah Makhdoom Ali , Shah Nasra M
Published: May 2007

Kuwait has, in recent years, achieved a marked improvement in the health status of its population, as measured by a variety of mortality and morbidity indicators. This can be attributed to the implementation of two sets of policies that impact upon health, namely the health and socio‐economic development plans of the Kuwaiti government. This article seeks to outline these recent changes in mortality and morbidity levels, and traces out the key policies considered to be the major determinants for these changes. Data is presented on health status, and on patterns and trends of health services' utilization. These trends suggest strongly that, for Kuwait, the health goals set for the year 2000 are achievable.
Reviewing the process and outcome of hospital care in Europe: The tracer method
Authors: Sanderson Colin , Bosch Theo , Goosen Jens , Hartwig Rudolph , Schelp Lothar
Published: May 2007

A method is described for reviewing and comparing the process and outcome of hospital care, which involves collecting data on a consecutive series of patients with the same medical condition. Criteria for choice of tracer condition are given, and illuminated with reference to fractured neck of femur. The method has been developed in the context of the European Collaborative Health Services Studies, and participants from five countries have been involved. It is concluded that the method is practicable and succeeds in its objectives. The role of health care managers is one of stimulus and support to doctors and nurses who might be interested in carrying out such studies, and a set of stages from the initial idea for a study, through study design and data collection to conclusions for practical change, is described.
Nurse managers and budgeting: Professional/bureaucratic conflict?
Authors: Abernethy Margaret A. , Stoelwinder Johannes U.
Published: May 2007

Professional/bureaucratic conflict theory suggests that the extent to which nurse managers use management control systems will depend on whether their goal orientation is to system rather than output or derived goals. This article examines the use of budgeting as a management control strategy, in relation to the goal orientation of nurse managers, in four large teaching hospitals. The goal orientations and use of budgeting by nurse managers is also compared with those of physician managers and other sub‐unit managers. The results indicate that nurse managers appear to be developing their goals of professionalization without a diminution of their organizational focus or their orientation towards providing a high standard of patient care.
Managing retrenchment in french public hospitals: Philosophical and regulatory constraints
Authors: Sobczak Patrick M. , Fottler Myron D. , Chastagner Daniel
Published: May 2007

The French hospital system is experiencing economic stresses similar to those experienced by US hospitals. Pressures for cost containment have occurred due to changes in health care funding. The public hospital system is facing unprecedented severe retrenchment. Innovative strategies for managing retrenchment have been restricted by regulatory and philosophical constraints. What is needed is to provide moreautonomyfor individual hospital managers together with greateraccountabilityfor achievement of results.
Recurrent costs in the health sector of developing countries
Authors: Waddington Catriona , Thomas Margaret
Published: May 2007

Widespread concern exists about the recurrent cost problems faced in the health sector of developing countries, and about the difficulties likely to be faced in the 1990s and beyond in seeking to expand further the movement to primary health care. The article accepts that the problem is a real one, and seeks first to define and measure it, and to put together some of the evidence on the scale of the problem. Next, the analysis involves an examination of its causes, and hence its solutions, exploring in some detail issues of budgetary control, management decision making, project selection, and the prospects for mobilizing additional recurrent funds to, and within, the health sector. The article concludes by drawing attention to the complex aetiology of the recurrent cost problem, and offers a five‐point plan of action if the problem is to be tackled seriously.
The equity principle in the allocation of health care expenditure on primary health care services in Portugal: The human capital approach
Authors: do Rosario Giraldes Mario
Published: May 2007

This article examines the equity principle as it could be applied to the financing of primary health care resources in Portugal. Three resource allocation criteria are considered: namely, the demand/utilization criterion; the health situation criterion; and, the coverage by health services criterion. With data based on health service expenditure, district by district, for 1983, the article shows that quite different results would emerge from the selection of one criterion rather than another. In particular, a policy of positive discrimination would reallocate resources towards the north rather than the south of Portugal, though differences would emerge between districts and between specific activities provided within the framework of primary health care. The results are presented and conclusions drawn.
A price to pay: The impact of user charges in ashanti‐akim district, Ghana
Authors: Waddington C. J. , Enyimayew K. A.
Published: May 2007

In present constrained economic circumstances, many governments have introduced or increased user charges for health services. This has been advocated by the World Bank, justified by reference to the raising of revenue, efficiency and, controversially, even the promotion of equity. This paper examines the impact of user charges on utilisation in the Ashanti‐Akim district of Ghana since the introduction of charges in 1985. In many ways, user charges have been a success: in recovering fees and maintaining urban utilisation. However some advantages have not materialised because the health infrastructure has not changed adequately. More importantly, equity and affordability have been problematical. For some of the population, services are no longer affordable.
Canada's provinces review their health services
Authors: Crichton Anne
Published: May 2007

Canada's health system is undergoing stocktaking and adjustment. Ontario and Quebec have recently reviewed their goals and strategies; other provinces have been seeking to control established programs. This article considers the political and social reasons for those reviews. Its themes ultimately concern whether equity is compatible with innovation and choice; whether downplaying technology is harmful; and whether restrictions (e.g. on medical manpower supply) can be achieved relatively painlessly. Changing political traditions in the different provinces have an effect upon their health systems, it is concluded.
From good medical practice to best medical practice
Authors: Jensen Uffe Juul
Published: May 2007

Medical and other professionals know what good practice is. It is in accordance with ideal procedures and standards of one's own practice. As actors we assess our practices from inside. If questions of quality assessment or quality assurance are raised at all, they are to be raised and answered by the professionals themselves. From that internal perspective, the idea of better or best medical practice is rejected as superfluous; or, perhaps, even nonsensical.

This article suggests that concepts of best medical practice, as expressed from outside the profession e.g. economic efficiency, are not adequate in themselves if our interest lies in changing existing practice. Defined from outside, such concepts would be alien to the medical profession.

Going from good practice to best practice, the article proposes, can be done on the basis of expanding the metaphor of self‐transcendence. In self‐transcendence the individual or profession changes or develops strategies and activities by adopting the standpoint of some perspective outside its own practice, and then integrating this perspective into practice.

Self‐transcendence by the medical profession can be carried out by their integrating a moral ideal from normal life into professional practice—essentially the notion of prescribing support of the weak. Such integration implies, inter alia, that the profession must take account of the scarcity of resources when assessing their practice.
Best medical practice: The case of Japan
Authors: Ikegami Naoki
Published: May 2007

‘Best medical practice’ can be given three different definitions. Definition A, by the medical profession, emphasizes the maintenance of technical standards in diagnosis and treatment. Definition B, by the essentially healthy general population, emphasizes preventive measures and the reassurance of the healthy status. Definition C, by the chronically sick and disabled, emphasizes rehabilitation and nursing care. Although each has its inherent weakness, each could be said to be describing an essential but distinct aspect of comprehensive health care which can be utilized to legitimize each party's claim for priority in the allocation of resources. Thus, the relative weight that is given to the three definitions of ‘best medical practice’ in society as a whole appears to be ultimately dependent on the social and cultural conditions unique to each country. In the case of Japan, Definition B has become the most dominant: it has resulted in the health care demands of the essentially healthy general population being well taken care of without excessive allocation to high technology medicine. However, a combination of demographic, technological and social changes will necessitate a different emphasis in the future.
Best medical practice in the Netherlands: A decision analyst's view
Authors: Kievit J. , Vissers T. , Casparie A. F.
Published: May 2007

Opinions over what is bad, good and best medical practice have varied through time. In older days, medicine aimed exclusively at maximum effectiveness through an aggressive diagnostic and therapeutic approach, irrespective of cost considerations. Budget constraints in health care have put limits on this exhaustive form of medicine. Consequently, considerations regarding the ratio between the quality and the cost of medical care are becoming more and more important in the definition of ‘best medical practice’. Quality standards in medicine thus should not be based exclusively on medical considerations, but should also take cost considerations into account. This balanced integration of quality and cost represents a new challenge in medicine. It demands an active interest and participation of the medical profession in budget affairs, and close cooperation between health care professionals, health economists, and health care administrators. If this integration is done explicitly and quantitatively, it requires the use of decision analysis and cost‐effectiveness analysis techniques.

Recent experiments at the department of Surgery at the Leiden University Hospital have demonstrated the feasibility of this approach. Quality standards were set by means of explicit outcome criteria, and policy changes were executed on the basis of cost‐effectiveness analysis. Quality of care could be maintained at the same or higher levels while cost savings of up to 60% were realized.

The advance of ‘best medical practice’ in the present and future requires a multidisciplinary approach to medicine, that is best realized by the use of explicit and quantitative quality standards. This approach can only be successful if close cooperation between professionals, administrators, economists and politicians in health care can be realized.
Best medical practice in practice: Measuring efficiency in mammography screening
Authors: Hall Jane
Published: May 2007

Breast cancer, screening and mammography have caused considerable debate in several countries. This article explores the concept of best medical practice in the context of mammographic screening for breast cancer. Maximizing the use of technology, ignores the risks intrinsic to technological intervention. To do no harm in modern medical practice means largely doing nothing. Best medical practice, therefore, requires a balancing of benefits and risks so that best practice is that which does more good than harm. At the same time, not all interventions that do more good than harm can be funded out of the current health care budget. Thus, best medical practice is economically efficient practice.

From the conceptual notion of what is best medical practice, this article turns to the problem of what that means in practical terms. Can we recognize best medical practice when it occurs? The identification, measurement and valuation of costs and benefits are discussed as a specific case study, in the context of breast cancer screening. Many of the difficulties involved here, particularly on the benefit side, are highlighted, especially in the context of QALYs. Yet, whatever the difficulties involved they have to be seen in the context of otherwise settling for something less i.e. inefficient medical practice.
Using drgs in developing referral policies for coronary care within a local health district
Authors: Bailey T. C. , Glaskin A. , Knowles D. , Kirby B.
Published: May 2007

This paper presents the results of a study into some specific aspects of the management of coronary heart disease within one district health authority. In particular, it is concerned with the appropriate balance of inpatient coronary care between the district general hospital and community hospitals in the light of current and potential changes in the clinical management of coronary cases.

The study is an example of a multidisciplinary approach to local health planning which is beginning to emerge within the Exeter Health District, the methodology of which may be applicable to client groups within the medical specialties other than coronary cases, such as strokes or respiratory disorders. It also illustrates the use of spatial analysis and diagnosis‐related groups in local planning.
Rural health insurance in Thailand: A case study from MAE NA sub‐district, Chiang Mai province
Authors: Adeyi Olusoji
Published: May 2007

This paper reports on a study carried out in July 1988 of the factors associated with membership of the rural health insurance programme in Mae Na, a sub‐district of Chiang Mai province in Thailand. It identifies appropriate interventions for sustaining the membership of the programme.

The Health Card Programme in Chiang Mai is the pilot phase of a national health insurance system in Thailand. Possession of a health card entitles the holder(s) to free treatment for a specified number of illnesses per year. The card holder is promised quick services via a ‘green channel’ in referral centres. Funds from card sales are used for reimbursing service providers, for community development, and for soft loans to card holders.

The main incentives for households to buy the health card were the expectations of free treatment, reduced waiting time at referral centres, and subsidized drugs. Eligibility for soft loans was not a major incentive for households to buy the health card. The promise of reduced waiting time was often not kept, resulting in consumer dissatisfaction and a preference for private, fee‐charging hospitals by the wealthier households. The timing of health card sales was not planned to coincide with the peak‐income post‐harvest season. The low income card for the poor, which guarantees free access to medical care, was readily available to the wealthy, but its impact on membership of the Health Card Programme is unclear.
‘Managing the cracks’: Management development for health care interfaces
Authors: Hunter David J.
Published: May 2007

The realm of public policy (including health policy) is, in many ways, more complex than that of decision‐making within the corporate organisations found in the private sector. The range of stakeholders is generally wider; many of the ways of influencing action are more subtle and indirect; and, arrangements for representation, accountability and consultation are correspondingly more elaborate. A future of this complexity in healthcare systems is the presence of numerous organisational and managerial interfaces. The paper considers three key sectors and the interfaces between them: primary health care, hospital care, and community care. Proposals for reforming the British National Health Service and community care services are destined to multiply the interfaces to be managed since they are predicated upon a split between purchasing services and providing them. The intention is to encourage a plurality of providers who will compete for contracts. The paper argues that the challenge posed by interface management is probably greater than any other in healthcare management. The requisite skills for successful interface management are reviewed. The paper concludes that these network skills are in short supply and that those responsible for management development in the NHS must tackle this lacuna as a matter of some urgency.
Central and local control in Nordic health care: The public organisation spectrum revised
Authors: Brogren Per‐Olof , Brommels Mats
Published: May 2007

One of the distinguishing characteristics of national health care systems is the degree of public involvement in service provision, funding and policy making. In international comparisons the Nordic countries are usually seen as a uniform group. Yet, the countries do have important differences, and a descriptive model was sought to demonstrate these, and, at the same time, to differentiate the concept of public control. Using the central‐local dichotomy, differences within the public framework were demonstrated between the countries, e.g. in methods of funding, financial regulation, formal planning instruments, and control of resource allocation. Financial control and planning were identified as two distinct components of public control. An analysis of the degree of centralisation along both dimensions separated the Nordic countries, which are otherwise homogenous as to public sector dominance.
Hospital strategy and regional planning in France
Authors: Frossard Michel
Published: May 2007

Cost containment policy in health implies changes in hospital management and regional planning. There is a movement in France towards the strategic management of hospitals and towards a new way of planning. That calls for new models and the paper presents, as an example, regional arrangements of neonatal care. Hospital managers and local authorities set up a model and an information system to allow the best way possible for involving hospitals in the building of a regional scheme, leading to the negotiation of contracts. This experiment is conducted by the National School of Public Health with the aim of gaining experience in bringing together professionals and teachers, doing research and producing materials for management development.
Estimating the financial savings from maintaining the level of acute services with fewer hospital beds
Authors: Beech Roger , Larkinson John
Published: May 2007

All district health authorities are obliged to use resources most efficiently. One approach to increasing efficiency is to identify measures which allow service levels, in terms of patients treated and standards of care, to be maintained at a lower cost. This could be achieved by maintaining service levels with fewer hospital beds. Reducing lengths of stay by removing organizational delays and expansions of day‐case care, are policies which can increase patient caseload per bed.

This paper puts forward an approach for estimating the resources released by such policies and assesses the savings achieved by realizing efficiency gains identified in a previous study by Beech et al. (1987). That study identified significant potential for maintaining services with fewer beds, with the expansion of day‐case care being a key mechanism. However this paper concludes that when services are maintained with fewer beds, the vast majority of hospital costs remain fixed. It also reaches the alarming conclusion that as a vehicle for reducing costs, day‐case care is much less effective than previous studies have implied.

However, increasing hospital throughput per bed does release capacity to treat more patients. The proposed reforms of the NHS (Secretaries of State, 1989) envisage an internal market for health care, allowing hospitals to enter into contracts with purchasers of health care. The approach to costing described in this paper is applicable to assessing the increased costs associated with such developments. These extra costs can then be compared with expected income.
Organizational development and privatization: A Bolivian success story
Authors: Fiedler John L.
Published: May 2007

This article presents a case study of a US Agency for International Development‐sponsored privatization effort in Bolivia. This privatization effort differs from AID's more common approach in that rather than merely helping already existing organizations to expand, this project has created a new organization. More ambitious and encompassing, this approach is also preferable because it directly addresses one of the most serious bottlenecks to economic development, viz., organizational development. The article describes the evolution of PROSALUD, a private, non‐profit network of 17 community‐sponsored health centers. The article describes factors and characteristics which have either conditioned or have directly contributed to PROSALUD's success. First, PROSALUD's health care environment is analysed, starting with a broad brush profile of select characteristics and trends which exist throughout the health setor of Bolivia, then narrows the focus to the local health sector. The structure and operations of PROSALUD are then analysed, focusing on the organization's managerial practices and financing and the series of tradeoffs it has been forced to strike: in its pricing strategy, between striving for financial viability and maintaining access to care; between, on the one hand, responding to community needs and demands and improving coverage by opening more facilities, and, on the other hand, focusing managerial efforts and outreach on a more limited number of clinics and neighborhoods; between providing a socially desirable mix of services—in particular, continuing to provide a great deal of free preventive care—and focusing care on more lucrative curative services; between maintaining commitments to neighborhoods and communities and eliminating the less economically viable (especially rural) clinics.