bluuebunny/crossref_metadata_2025_split huggingface dataset:
French General Practitioners’ Attitudes toward Therapeutic Advances in HIV Care: Results of a National Survey
Authors: Obadia Y , Souville M , Morin M , Moatti J-P 
Published: October 2002

We aimed to assess attitudes to French primary care providers towards recent advances in HIV care. Telephone surveys in a random sample of French general practitioners (GPs) were carried out in April 1996 (response rate=70.3%; n=1186). Only 40.5% of the sample had participated in the regular medical follow-up of HIV-infected patients during the previous year. Among these 480 respondents, only a few (13.3%) declared that they would take care of an asymptomatic patient with a high (>500 cells/mm3) CD4 count as the unique provider. A majority (66.2%) had referred at least one HIV-infected patient to a hospital specialist in the previous year. A total of 31.4% declared that they considered it appropriate for an antiretroviral treatment to be initiated to an asymptomatic patient with 300 CD4 cells/mm3, and only 23.5% were already in favour of combination therapies rather than zidovudine monotherapy as treatment of choice. GPs with the most experience with HIV care tended to be the most reluctant to modify their attitude in favour of earlier initiation of antiretroviral therapies and of the switch from monotherapy to combination therapies. The survey suggests there is a gap between attitudes of GPs and those of AIDS specialists toward preliminary reports of therapeutic advances in HIV care. Whether or not such a gap may create problems for an appropriate diffusion of new antiretroviral therapies should be carefully monitored, in the context of current reforms emphasizing the key role of primary providers in most health-care systems.
Can simulation be used to reduce errors in health care delivery? The hospital drug distribution system
Authors: Dean Bryony , Barber Nick , van Ackere Ann , Gallivan Steve 
Published: October 2002

Objectives: To construct a simulation model of the hospital drug distribution system, to evaluate the effects of different changes to the system on unavailability-related medication administration errors (U-MAEs), to test the most promising system in a controlled trial and to explore the model's validity. Methods: A discrete-event simulation model of the drug distribution system was constructed, using data collected on a vascular surgery ward and a renal medicine ward as model inputs. The model's output was the U-MAE rate. The model was used to explore the effects on U-MAEs of different changes to the system. One of the changes predicted to reduce U-MAEs, a patients' own drugs scheme, was introduced on each study ward; U-MAE rates were measured using observations before and after its introduction and compared with those predicted by the model. Results: The model predicted that the introduction of a patients' own drugs system would reduce unavailability-related errors on each ward; in practice, there was a slight decrease on the medical ward but an increase on the surgical ward. Reasons for these findings were explored and four contributing factors identified. Three of these related to failure to follow hospital procedures, the fourth to an issue for which no policy existed. If these factors had been taken into account, the error rates predicted by the model would have been similar to those observed. Conclusions: Simulation modelling is a potentially useful approach to the study of U-MAEs, although care must be taken to ensure that such models reflect actual practice rather than stated policy.
Vascular patients' preferences for local treatment: an application of conjoint analysis
Authors: Shackley Phil , Slack Russell , Michaels Jonathan 
Published: October 2002

Objectives: To investigate whether and to what extent vascular patients are willing to trade expected health outcomes for improvements in non-health benefits, such as the availability of local services, in the provision of peripheral vascular surgery. Methods: Conjoint analysis was used to elicit patient preferences via a mailed questionnaire. Respondents were asked to consider pairwise descriptions of vascular services described in terms of a number of key attributes and asked to indicate which scenario description they preferred. Multivariate regression analysis was used to estimate the relative importance of the attributes to respondents. Results: Of the 339 patients invited to participate, 161 (47%) returned a completed questionnaire, although 36 (11%) were found to be internally inconsistent and could not be used, leaving 125 (36%) for analysis. An unexpected problem arose with respect to the design of the conjoint analysis questionnaire. Specifically, three of the attributes in the regression model were found to be collinear. The source of this problem, how it was overcome and how it can be avoided in future studies is discussed. The results of the regression analysis indicated that the patients who responded had a preference for local treatment to the extent that they were willing to incur increased risks of perioperative mortality and amputation to receive treatment at their local hospital. These results are discussed in connection with those from a different study which elicited patient preferences for local treatment using a standard gamble technique. Conclusions: Policy-makers, when considering the potential benefits of regionalising health care, should seek to elicit the preferences of those patients who will be affected by the reorganisation.
Decision aids: are they worth it? A systematic review
Authors: Estabrooks Carole , Goel Vivek , Thiel Elaine , Pinfold Patricia , Sawka Carol , Williams Ivan 
Published: October 2002

Objectives: The field of consumer decision support interventions has grown rapidly in the last 20 years, particularly since the increased formalization of evidence-based decision-making in health care. However, little is known as yet about the effect these decision aids have on relevant outcomes. To identify outcomes influenced by consumer decision aids (CDAs) and the particular effects of CDAs on those outcomes. Method: Published reports of randomized controlled trials and other designs in English identified from searches of Medline, Cancerlit, CINAHL, PsycINFO, Social Science Abstracts, the Cochrane Library and Current Contents, and from ancestry searches, hand searches and consultation with key informants. Studies were included if consumers were the decision-makers, decisions were real and not hypothetical, the intervention met a strict definition of a CDA and decisions involved treatment or screening. Data on setting, subjects, decision types, decision aid features and outcomes were extracted. The validity of each study included was evaluated by two team members. Summative ratings were calculated and categorized as high, medium and low. Results: Over 500 titles were initially assessed; 96 study reports were obtained and screened for inclusion. Twenty-two reports representing 20 studies met the inclusion criteria. Eight studies with a low rating were excluded. Results were synthesized from the remaining 12 studies. Published studies of CDAs are increasing although still few in number. Outcomes such as knowledge and decision-making processes are influenced by CDAs but effects on treatment preferences, the actual decision or other outcomes have yet to be clearly established. Conclusions: Improved outcomes result from the use of CDA in some categories of outcome but insufficient evidence exists yet to support improved outcomes in all categories or to evaluate whether, given the considerable costs of many CDAs, funding for extensive ongoing development and testing can be sustained.
Twenty-five years of programme budgeting and marginal analysis in the health sector, 1974-1999
Authors: Mitton Craig , Donaldson Cam 
Published: October 2002

Objectives: Programme budgeting and marginal analysis (PBMA) is a priority setting framework that has been used over the last 25 years in the health sector. To date, no formal evaluation of this framework has been conducted. The aims of this study were to categorize previous PBMA exercises systematically and determine the impact of PBMA in regional health authorities (RHAs) internationally. Methods: Thirty authors of grey literature and published papers on PBMA, and an additional six economists with research interests in PBMA, were surveyed with a mailed questionnaire. Previous exercises were categorized and details of the short- and long-term impacts of the framework were obtained. Descriptive statistics and content analysis were used. Results: The PBMA framework was identified as having been used 78 times in 59 RHAs. For the exercises where longer-term impact was known, the approach was viewed as having had a positive impact, as defined by the setting of priorities or shifting of resources, in 59% of cases and continued to be used in at least 52% of the RHAs. The primary reasons why PBMA was discontinued included personnel changes and lack of internal 'champions'. Conclusions: Contrary to popular perception, there has been widespread diffusion of PBMA in RHAs internationally and, overall, the impact of this approach has been positive. Although there is general agreement on the validity of the economic principles underlying PBMA, addressing managerial issues would seem to be central to successful implementation in a given region.
Health needs assessment and needs-led health service change: a survey of projects involving public health doctors
Authors: Jordan Joanne , Wright John , Ayres Philip , Hawkings Martin , Thomson Richard , Wilkinson John , Williams Rhys 
Published: October 2002

Objectives: To describe the criteria that define an effective health needs assessment and to explore which factors are important for the delivery of effective health needs assessment in the English National Health Service (NHS). Methods: A postal questionnaire to all public health doctors in an English health region to describe health needs assessment activity, including initiating factors, methods and outcomes. This was followed by semi-structured interviews with public health professionals and others involved in 10 purposively selected needs assessments. Results: A response rate of 62% identified a total of 102 health needs assessments undertaken between 1993 and 1998. A number of themes emerged as being important in the impact of health needs assessments on policy and planning. These included careful design, methodological rigour, decisive leadership, good communication, involvement and ownership of the work from relevant stakeholders, support from senior decision-makers, appreciation of the political dynamics and engagement with local priorities, availability of resources and, finally, an element of chance. These themes can be categorised broadly into contextual factors and quality or robustness of the work. Our findings suggest that, although methodological and analytical quality are necessary characteristics of effective health needs assessment, they are not sufficient without a favourable political environment. Conclusion: There appear to be conditions under which needs assessment is more likely to be effective in terms of its influence on policy and planning. However, it is clear that needs assessment does not occupy a central position in health service decision-making, remaining vulnerable to a range of factors over which those responsible for its conduct have little or no control.
The test-retest reliability of the modified Patient Generated Index
Authors: Tully Mary , Cantrill Judith 
Published: October 2002

Objectives: The purpose of this study was to determine the test-retest reliability of the recently modified Patient Generated Index (PGI) when used as a self-completed postal questionnaire by older people with arthritis. Methods: Two sets of postal questionnaires were used, sent two weeks apart, followed by interviews with a theoretically chosen subsample of respondents to both. Reliability for respondents whose health had not changed in the intervening two weeks was assessed using intraclass correlation coefficients. Data from interviews were used to develop theories to select subgroups for analysis. Results: One thousand one hundred and twenty-nine people over 65 years old with arthritis were surveyed and 53 were selected for interview. The response rates to the two surveys were 78% and 83%, respectively. Complete data for the test-retest analysis were available from 236 (29.2%) respondents. The intraclass correlation coefficient ( ri) was 0.55 [95% confidence interval (CI) 0.43 to 0.64, P < 0.0001]. The most optimistic range for the limits of agreement was 64.66 around the difference between two total PGI scores. The intraclass correlation coefficient decreased considerably if there had been more than six changes to the areas chosen for inclusion on the second occasion ( ri = 0.37, 95% CI 0.01 to 0.65, P < 0.05). Interview data showed that some respondents incorrectly interpreted the scoring instructions, often inconsistently. When their data were excluded, the intraclass correlation coefficient increased to 0.67 (95% CI 0.56 to 0.76, P < 0.0001). Conclusions: The results indicate that the modified PGI may be sufficiently reliable for within-group comparison of elderly people with arthritis, but not for assessing individual patients. However, it also elicits individual patient concerns and priorities about disease that other questionnaire-based instruments may not identify.
How comprehensive are the basic packages of health services? An international comparison of six health insurance systems
Authors: Polikowski Marc , Santos-Eggimann Brigitte 
Published: October 2002

Objectives: Interest in the composition of the health care menu has grown. Its outwardly comprehensive nature is as rhetorical as the slogans of universal access and affordability. This paper summarizes the international part of a report to the Swiss government, in which we explored the basic package of services covered by social health insurance in France, Germany, Israel, Luxembourg, The Netherlands and Switzerland. The aim of the initial report was to check the appropriateness of the Swiss catalogue, with special attention to the risk of unequal access to health care by rationing of effective services. In this paper, we highlight the major differences in service coverage between the countries and address the possible factors explaining those differences. Methods: The contents of the basic packages of the six countries were compared using data from government ministries and sickness funds. Results: Coverage is most comprehensive in Germany and Switzerland; these are also the countries with the greatest total health expenditure. Three countries separated nursing care from other types of health care by creating an independent insurance scheme. Some health care benefits are also covered under the heading of social care. High out-of-pocket payments are increasingly used as hidden rationing instruments. Conclusions: The present comparison highlights the multi-factorial character of the choices made in six countries in order to keep their health care menu within the possibilities offered by available resources.
The impact of managed care and practice size on primary care physicians' perceived ability to refer
Authors: Xu Tom , Rohrer James , Borders Tyrone 
Published: October 2002

Objectives: To identify the determinants of primary care physicians' perceived ability to refer patients, to compare perceived ability to refer between solo/two-physician practices and group practices, and to determine the impact of managed care on perceived ability to refer. Methods: Multivariate analysis using a dataset derived from the Community Tracking Study Physician Survey, 1996-1997. The variables used to explain physicians' perceived ability to refer included physician and practice characteristics as well as aspects of the financial arrangements of managed care. The sample was stratified by practice size. A likelihood ratio test was performed to determine whether there were differences in practice characteristics and managed care financial arrangements that could explain variations in perceived ability to refer between physicians in solo/two-physician and group practices. Results: Perceived ability to refer did not vary much between physicians in solo/two-physician practices and those in group practices. However, the determinants of perceived ability to refer did vary by practice size. The effects of physicians' characteristics were more pronounced among physicians in group practice, whereas the effects of financial arrangements were significant for physicians in solo/two-physician practices. The most significant determinant of perceived ability to refer was primary care physicians' satisfaction in their communication with specialists. Conclusion: Group practices are more immune than solo/two-physician practices to external financial arrangements from managed care contracts, possibly through their ability to take advantage of economies of scale and to diversify their sources of funds.
Multiple sclerosis and quality of life: a qualitative investigation
Authors: Somerset Maggie , Sharp Deborah , Campbell Rona 
Published: October 2002

Objectives: Many people who live with long-term illness experience a decline in their quality of life. The primary aim of this qualitative study was to identify aspects of life that contributed to the quality of the lives of people who had one particular chronic illness, namely multiple sclerosis (MS). A secondary aim was to use this information to highlight areas where there was potential for effective intervention by health or social services. Methods: Sixteen people with MS who lived in a variety of circumstances and had a range of disabilities were interviewed in depth. Views relating to personal experience of chronic illness, diagnosis, living with disability, and conventional and alternative treatments were explored. Transcripts were analysed using a grounded theory approach. Results: Analysis of the interviews revealed that being subjectively reasonably happy and as socially active as desired was central to an acceptable quality of life. The extent of the personal control that participants were able to exert and their individual illness trajectory were found to be central to whether or not this aim was achieved. In addition, the importance of social comparison was revealed, although its influence upon quality of life was somewhat inconsistent. A number of other factors were found to play an influential role in the quality of people's lives. These are described and plausible links between factors are proposed. Conclusions: Many aspects of living with chronic illness are unavoidable, but health or social intervention can affect others. Inappropriate personal assistance may result in dependency, which detracts from personal control and worsens quality of life. When appropriate, however, support may have beneficial consequences. By recognising the specific factors that link personal control and the illness trajectory, appropriate and timely support can be negotiated.
'Inappropriate' attendance at an accident and emergency department by adults registered in local general practices: how is it related to their use of primary care?
Authors: Martin Alison , Martin Christopher , Martin Peter B , Martin Peter AB , Green Gill , Eldridge Sandra 
Published: October 2002

Objectives: To identify the relationship between 'inappropriate' attendance at an accident and emergency department (AED) by adults registered with local general practices and their use of primary care. Methods: A case-control study matched for age, sex, distance from the AED, social class and registered general practice and set in a single AED and two health centres in South Essex. The participants were a total of 452 patients over 15 years old from the two health centres classified as having attended the AED 'inappropriately' in 1997 as identified by a modified Sheffield process method, and 452 controls. The predictive variables were measures of utilisation in the year 1997, including number of contacts in primary care, referral and investigation costs. Measures of morbidity were collected as potential confounders. These included a recorded history of anxiety or depression in the year 1997, or being in receipt of repeat prescriptions in that year. Results: The rate of 'inappropriate' attendance was 16.8% {95% confidence interval (CI): 15.7-18.0}. All measures of utilisation and markers of anxiety and depression were significantly positively associated with 'inappropriate' attendance, but there was no association with markers of chronic morbidity. Only the number of general practitioner (GP) appointments ( P < 0.0001) and out-of-hours advice calls ( P < 0.0001) were independently correlated with 'inappropriate' attendance in a conditional logistic regression. 'Inappropriate' attendees had approximately twice as many GP appointments and 10 times as many out-of-hours telephone contacts with the GP. Conclusions: GP-registered, 'inappropriate' attendees at AEDs utilise primary care services more than matched controls; this pattern of service utilisation appears to be unrelated to chronic physical illness. Thus, simply providing new, directly accessible primary health care services may not significantly reduce AED use.
Systematic review of evidence for the benefits of telemedicine
Authors: Hailey David , Roine Risto , Ohinmaa Arto 
Published: October 2002

summary A systematic review of telemedicine assessments based on searches of electronic databases between 1966 and December 2000 identified 66 scientifically credible studies that included comparison with a non-telemedicine alternative and that reported administrative changes, patient outcomes, or results of economic assessment. Thirty-seven of the studies (56%) suggested that telemedicine had advantages over the alternative approach, 24 (36%) also drew attention to some negative aspects or were unclear whether telemedicine had advantages and five (8%) found that the alternative approach had advantages over telemedicine. The most convincing evidence on the efficacy and effectiveness of telemedicine was given by some of the studies on teleradiology (especially neurosurgical applications), telemental health, transmission of echo-cardiographic images, teledermatology, home telecare and on some medical consultations. However, even in these applications, most of the available literature referred only to pilot projects and to short-term outcomes. Few papers considered the long-term or routine use of telemedicine. For several applications, including teleradiology, savings and sometimes clinical benefit were obtained through avoidance of travel and associated delays. Studies of home care and monitoring applications showed convincing evidence of benefit, while those on teledermatology indicated that there were cost disadvantages to health-care providers, although not to patients. Forty-four of the studies (67%) appeared to have potential to influence future decisions on the telemedicine application under consideration. However, a number of these had methodological limitations. Although useful clinical and economic outcomes data have been obtained for some tele-medicine applications, good-quality studies arestill scarce and thegeneralizability of most assessment findings isratherlimited.