Occupational Health and Safety Issues among Vegetable Farmers in Trinidad and the Implications for Extension.

Trinidad has an aged farming population. For a host of reasons, young persons are not entering the agricultural sector; therefore, these aged farmers will continue to be the backbone of the industry. Hence, there is much need for improving the health and safety of the workers within this sector. This first-time study assessed the prevalence of occupational health and safety disorders and discomforts among Trinidad's vegetable farmers in an attempt to understand the extent of the problem within the general farm population. The implications for extension are highlighted, and several recommendations are provided. Small-scale commercial-oriented vegetable farmers (n = 100) from ten of the most populated agricultural areas across Trinidad were surveyed. Results indicated that there was an overall moderate prevalence of occupational injuries among vegetable farmers. Most prevalent were musculoskeletal disorders of the lower back and upper body extremities, watery/burning eyes, skin rashes/itching, headaches, fatigue, dehydration, stress, and injuries attributed to slips and falls. Based on the evidence that a problem exists with health and safety, the extension service can now prepare and deliver programs to educate farmers on the actions necessary to improve their personal health and safety and that of their workers. This type of study has not been done before among farmers in Trinidad. It brings a very important and timely issue to the fore because of the aged farming population. Additionally, since the farmer profile and farming systems are similar in the wider Caribbean, policy makers can take note of the findings and recommendations and embrace actions.

Cost-minimization analysis of treprostinil vs. epoprostenol as an alternate to oral therapy non-responders for the treatment of pulmonary arterial hypertension.

INTRODUCTION: Idiopathic pulmonary arterial hypertension (IPAH) is associated with substantial morbidity and mortality. Treprostinil was compared to epoprostenol for the economic impact of treating IPAH patients who failed or were not candidates for bosentan. METHODS: The model was a cost-minimization analysis, assuming clinical equivalence was achieved by proper dosing of both drugs, in terms of survival and surrogate measures. Two theoretical cohorts of 270 patients were treated with subcutaneous treprostinil and intravenous epoprostenol, and were evaluated over 3 years using a spreadsheet model. Annual survival rates were estimated for the cohorts so that at endpoint 114 (42%) patients survived in both groups. The model utilized resource valuation data for medication and supply costs from Medicare; hospital, consultation, surgical, and diagnostic procedural fees from North Carolina hospitals; and costs to treat adverse events from published sources. Costs were obtained from standard lists and were presented as 2003 US dollars, discounted at 3%. Sensitivity analyses were performed testing all model uncertainties. RESULTS: In the base case analysis, treprostinil demonstrated savings of 22,701 US dollars and 37,433 US dollars per patient over 1- and 3-year time horizons, respectively. The greatest savings came from reduced or minimal hospitalizations attributed to the dose titration and treatment of adverse events, such as sepsis, associated with epoprostenol and its delivery system. Probabilistic sensitivity analyses resulted in average 3-year cost-savings of 41,051 US dollars (Standard Deviation = 13,902 US dollars) per patient. CONCLUSIONS: By initiating and continuing treatment with treprostinil over a 3-year period, the economic burden associated with IPAH may be reduced compared to treatment with epoprostenol. The greatest saving with treprostinil was attributed to decreased sepsis.

Gaining and maintaining commitment to large-scale change in healthcare organizations.

Healthcare administrators have sought to improve the quality of healthcare services by using organizational change as a lever. Unfortunately, evaluations of organizational change efforts in areas such as total quality management (TQM), continuous quality improvement (CQI), and organizational restructuring have indicated that these change programmes have not fulfilled their promise in improving service delivery. Furthermore, there are no easy answers as to why so many large-scale change programmes are unsuccessful. The aim of this analysis is to provide insights into practices that may be utilized to improve the chances of successful change management. It is proposed that in order to effect change, implementers must first gain commitment to the change. This is done by ensuring organizational readiness for change, surfacing dissatisfaction with the present state, communicating a clear vision of the proposed change, promoting participation in the change effort, and developing a clear and consistent communication plan. However gaining commitment is not enough. Many change programmes have been initially perceived as being successful but long-term success has been elusive. Therefore, maintaining commitment during the uncertainty associated with the transition period is imperative. This can be done by successfully managing the transition using action steps such as consolidating change using feedback mechanisms and making the change a permanent part of the organization's culture.

Break-even analysis revisited: the need to adjust for profitability, the collection rate and autonomous income.

This paper modifies traditional break-even analysis and develops a model that reflects the influence of variation in payer mix, the collection rate, profitability and autonomous income on the desired volume alternative. The augmented model indicates that a failure to adjust for uncollectibles and the net surplus results in a systematic understatement of the desired volume alternative. Conversely, a failure to adjust for autonomous income derived from the operation of cafeterias, gift shops or an organization's investment in marketable securities produces an overstatement of the desired volume. In addition, this paper uses Microsoft Excel to develop a spreadsheet that constructs a pro forma income statement, expressed in terms of the contribution margin. The spreadsheet also relies on the percentage of sales or revenue approach to prepare a balance sheet from which indicators of fiscal performance are calculated. Hence, the analysis enables the organization to perform a sensitivity analysis of potential changes in the desired volume, the operating margin, the current ratio, the debt: equity ratio and the amount of cash derived from operations that are associated with expected variation in payer mix, the collection rate, grouped by payer, the net surplus and autonomous income.

Factors contributing to the amount of vehicular damage resulting from collisions between four-wheel drive vehicles and passenger cars.

This study examines the vehicular damage resulting from motor vehicle crashes involving four-wheel drive vehicles and passenger cars in the state of Oklahoma. In particular, the focus of the analysis is on differences in vehicular damage to passenger cars and four-wheel drive vehicles. Results indicate that passenger cars sustain significantly greater vehicular damage than four-wheel drive vehicles. In addition, several other factors significantly influence the level of damage resulting from collisions between four-wheel drive vehicles and passenger cars. Driver behavior or unsafe acts, represented by the rate of travel prior to the collision, failure to yield, failure to obey a stoplight or a stop sign, the consumption of alcohol and the use of drugs, also contributed to the amount of vehicular damage. In addition, results also indicate that the level of damage was influenced significantly by environmental factors, represented by a reduced intensity of light, wet or slippery roadways and the type of collision. The findings reinforce the importance of a number of policy initiatives that may reduce the vehicular damage resulting from collisions involving four-wheel drive vehicles and passenger cars. For example, the study indicates a need to initiate legislation that lowers the speed limit during dark and twilight hours, commits additional resources to road maintenance to reduce unsafe road conditions, and stimulates improvements in automotive design that provide better lateral protection to vehicles.

Impact of health system factors on changes in human resource and expenditures levels in OECD countries.

In order to gain further insight into the system factors responsible for changes in the health workforce, this study undertook an empirical examination of the determinants of the size of the health workforce and overall health expenditures across fifteen OECD countries. Specifically, using the latest release of OECD data, the analysis estimated and evaluated the effects of variables such as the proportion of female physicians and the elderly, expenditures on ambulatory care, enrollment levels in training programs, level of public financing, and per capita income on the size of the health workforce and level of health spending between 1970-1991. The findings of this study help to place the problem of the changing health workforce within the context of the complexity of health systems. It confirms any understanding of what accounts for changes in the size of the health labor force and expenditures require disentangling the effects of variables which needs to be taken into account when considering health system reforms.

Equity concerns with the use of hospital services by the medically vulnerable.

This study assessed distributional inequities in access to care among a representative sample of adults residing in Oklahoma. Inequities were identified by comparing the medically vulnerable to the less vulnerable with respect to their use or nonuse of hospital care and, among those admitted, the number of days of care consumed. The behavioral model was employed to guide the analysis and the development of hypotheses. Controlling for need, enabling, and predisposing factors, the results indicate that the use of service by the poor, the elderly who lack supplemental insurance, and the uninsured is incongruent with their health status and that current methods of financing care may contribute to distributional inequities. The implications of these findings are discussed in the context of options that may improve access to care by the medically vulnerable.

Health risks, ability to pay, and the use of primary care: is the distribution of service effective and equitable?

BACKGROUND: This study clarifies the confusion about what factors are consistent predictors of primary care service use, of which preventive services are a major component. A variety of health risk, predisposing, and enabling characteristics were assessed for their association with the use of primary care. Variable selection was guided by the use of the Andersen-Newman Behavioral Model of health service utilization. METHODS: The responses of 1,512 residents of Oklahoma to the BRFS survey were used in this study. Both probit and logistic analyses were used to assess the use of nine preventive services and a summary index of service use. RESULTS: The results indicate that those at greater risk of illness and least able to use finance services have the lowest rates of use among the nine preventive services individually and when combined as an index of overall primary care use. CONCLUSIONS: Problems persist with the adequate distribution of primary care among the medically vulnerable. Furthermore, recent welfare and health reforms may present added obstacles to their access to quality primary care services. The paper concludes with a discussion of policy options that may improve the effectiveness of primary care and redress inequities in the use of these services.

Organizational justice principles and large-scale change: the case of program management.

Many of the barriers to implementation of large-scale change in healthcare organizations seem to be related to a lack of attention to the human change that needs to occur. One element of this human dimension that change agents overlook is the role that perception of fairness to employees plays in implementing large-scale organizational change. This article uses program management (an organizational design that has been implemented in many healthcare facilities across Canada) as an example of large-scale structural change and demonstrates the importance of applying procedural and interactional justice principles to enhance the implementation of organizational change.

Pharmacological characterization of the response of the leech pharynx to acetylcholine.

In this study we document the sensitivity of the leech pharynx to acetylcholine and begin to characterize the acetylcholine receptor mediating this response by examining the effects of selective cholinergic agonists and antagonists on the contractile behavior of the pharynx. The order of potency derived from the EC50 of each agonist was (+/-)epibatidine > acetylcholine (in the presence of physostigmine) >> McN A-343 >> carbachol > nicotine. However, when response amplitude was considered, the order of potency to the tested agonists was (+/-)epibatidine >> nicotine >> McN A-343 >> carbachol > acetylcholine. Acetylcholine-induced contractions of the pharynx were antagonized by d-tubocurarine, but not by alpha-bungarotoxin, alpha-conotoxin M1, or mecamylamine. Application of high concentrations of hexamethonium (1 mM) augmented the acetylcholine-induced contractions. However, this augmentation was apparently due to inhibition of acetylcholinesterase by hexamethonium. The muscarinic antagonist atropine produced complex actions and apparently acted as a mixed agonist/antagonist. Atropine by itself produced an increase in basal tonus and increased the frequency and amplitude of phasic contractions. Atropine increased the peak tension of the acetylcholine-induced response; however, it reduced the amplitude of both the acetylcholine-induced increase in basal tonus and integrated area. Based on the pharmacological profile of the pharyngeal acetylcholine response, we conclude that the acetylcholine receptor mediating the response is a nicotinic receptor. However, the responsiveness of the pharynx to muscarinic agents diverges from that of a classical nicotinic receptor.

Cross-national comparison of capitation funding: the American, British and Dutch experience.

In this paper we review the performance of the capitation payment systems of three countries--the Adjusted Average Per Capita Cost (AAPCC) system used in the United States to reimburse Health Maintenance Organizations (HMOs) for insuring Medicare recipients, a somewhat similar system in the Netherlands which reimburses third-party payers for insuring the entire population and a weighted system utilized in Britain for regional funding. Our review revealed significant problems with the current version of the AAPCC formula as there is evidence of the biased selection of beneficiaries and actual losses to Medicare through its use. Furthermore, several studies show that the demographic adjusters utilized in the AAPCC formula are extremely poor predictors of future healthcare utilization relative to the potential of direct and indirect health status measures. The Dutch experience with capitated funding has been similar to that of the United States. While Dutch researchers have built on the work of their American counterparts they acknowledge that further work is needed before a fully functional system is implemented. Britain's weighted system has fulfilled its original mandate to redistribute healthcare resources based on population need but recent changes giving increased influence to age weighting could reverse some of these gains. A number of proposed improvements to these risk adjustment problems were reviewed including the development of diagnostic cost groups, the coexisting hierarchical conditions model and the use of community-rated high-risk pooling. The findings from this study can help others narrow the alternatives they need to consider when thinking of introducing capitation funding or refining already existing systems.

Evaluating reference-based pricing: initial findings and prospects.

Reference-based pricing is a controversial policy mechanism used to control pharmaceutical expenditures. After its implementation in some European countries, the British Columbia government introduced a version of reference-based pricing in October 1995. The authors reviewed previous studies of reference-based pricing in other countries and conducted a preliminary assessment of the impacts of the BC system by analysing secondary utilization and cost data. After the introduction of reference-based pricing in other jurisdictions within the Organisation for Economic Cooperation and Development, there was a temporary reduction in the rate of growth of total pharmaceutical expenditures, followed by a return to previous growth trends in subsequent years. Similarly, initial data from BC showed dramatic declines in annual expenditures for drugs within referenced categories (from $42.0 million the year before reference-based pricing was introduced to $23.7 million the year after). Although early evidence suggests that reference-based pricing in BC is indeed reducing drug expenditures, much more research is needed to make a final determination of its success. A more comprehensive and longitudinal evaluation of reference-based pricing is needed and should take into account a wide range of non-cost impacts, the most important of which are the effects on health outcomes.

A review of organizational performance assessment in health care.

As health care organizations look for ways to ensure cost-effective, high quality service delivery while still meeting patient needs, organizational performance assessment (OPA) is useful in focusing improvement efforts. In addition, organizational performance assessment is essential for ongoing management decision-making, operational effectiveness and strategy formulation. In this paper, the roles and impact of OPA models in use in health care are reviewed, and areas of potential abuse, such as myopia, tunnel vision and gaming, are identified. The review shows that most existing OPA models were developed primarily as sources of information for purchasers or consumers, or to enable providers to identify areas for improvement. However, there was little conclusive evidence evaluating their impact. This review of existing OPA models enabled the establishment of principles for the development, implementation and prevention of abuse of OPA specific to health care. The OPA models currently in use in health care may provide managers with false confidence in their ability to monitor organizational performance. To further enhance the field of OPA, areas for future research are identified.

Prediction of the financial performance of Ontario hospitals: a test of environmental determinist and adaptationist perspectives.

While other industries for many years have been concerned with the problem of financial distress, it is only recently that this issue has become a matter of interest to hospital managers, policy makers, and the general public. However, the determinants of hospital financial performance are neither well studied nor understood. The objectives of this study were to identify factors that affect the financial performance of Ontario hospitals and to construct a model that could be used to predict financial performance in the future. A number of organization and environmental factors that could influence financial performance were postulated and then tested for their statistical impact and predictive ability. Cross-sectional data over the 3-year-period 1986-1988 for 223 Ontario public hospitals were used. The first 2 years of data served as a derivation sample for hypothesis testing and development of a predictive model. The third year of data was used as a holdout sample for cross validation. Information on the variables investigated came from secondary sources, in particular Statistics Canada's Annual Hospital Returns. Univariate analyses revealed distressed hospitals were more likely to earn more revenues from non-government sources, to be non-teaching institutions and have longer chronic lengths of stay, and to be found in areas with higher per capita incomes, number of females in the population, physician supply, and area wage rates. A five variable prediction model was developed which accounted for 25% of the variance in financial performance in the derivation sample and on cross validation dropped to 21%. The model identified greater hospital size, older plants, higher technological complexity, more intensive care services, and location in areas with more females to be significant predictors of financial distress. Overall, environmental factors (community and structural characteristics) were more important in influencing financial performance. The implication for hospital managers is to underscore that an important dimension of successful leadership requires they remain outwardly focused and involved in managing the external environment. For policy makers the need is to develop funding formulae which encourage efficiency and are also responsive to differences in community and structural characteristics across hospitals.

Pharmacoeconomic analysis of empirical therapy with ceftazidime alone or combination antibiotics for febrile neutropenia in cancer patients.

There is evidence to suggest that single-agent broad spectrum antibacterials may be cost-effective alternatives to combination antibiotics for the empirical management of febrile neutropenia in cancer patients. The objectives of the present study were 2-fold. The first objective was to compare the clinical effectiveness of ceftazidime monotherapy with that of 2 combination antibiotic regimens in cancer patients with febrile neutropenia. The 2 comparator regimens consisted of tobramycin plus piperacillin, either with (regimen 'CAP') or without (regimen 'AP') cefazolin. The second objective was to perform a cost-effectiveness analysis of the 3 regimens. Meta-analysis of randomised comparative trials between the 3 therapy groups was performed to determine the average overall response rate after 3 to 5 days of treatment. Seven clinical studies were selected for analysis. The overall incidence of adverse drug reactions (ADRs) was determined using the results of comparative and noncomparative studies. A comparative cost-analytic model was applied from a hospital perspective. The costs of primary therapy, hospitalisation, laboratory tests, routine patient care and treating ADRs were calculated, as were future costs. Monotherapy with ceftazidime was associated with an overall response rate of 63.5% and mean per-patient costs of $Can12,000 to $Can14,000. In comparison, regimen AP was associated with an overall response rate of 58.8% and mean costs of $Can13,000 to $Can16,000 per patient. The overall response rate in patients receiving CAP was 75.3%, and the mean cost per patient was $Can11,000 to $Can12,000. Thus, regimen CAP was the most cost-effective therapy from a hospital perspective.

Quality of abstracts of original research articles in CMAJ in 1989.

PURPOSE: To evaluate the quality of abstracts of original research articles. DESIGN: Blind, criterion-based survey. SAMPLE: Systematic sample of 33 abstracts of original research articles published in CMAJ in 1989. MEASUREMENT: The quality of abstracts was measured against a checklist of evaluation criteria, which were divided into eight categories. A score for each abstract was obtained by dividing the number of criteria present by the number applicable. The overall mean score was also determined. RESULTS: The overall mean score of abstract quality was 0.63 (standard deviation 0.13) out of 1. Of the abstracts reporting study design 56% did not include specific technical descriptors. About 52% did not explicitly describe the study variables. In describing subject selection 79% failed to use specific technical terms. Of the abstracts reporting results 66% did not provide appropriate supporting data. Of those that gave conclusions 86% did not address study limitations and 93% made no recommendations for future study. CONCLUSION: Most of the abstracts provided some information pertaining to each evaluation criterion but did not provide detail sufficient to enhance the reader's understanding of the article. On the basis of the study sample the abstracts need improvement in description of research design, reporting of subject selection and results, and statements of limitations and recommendations. The small sample from one journal and the absence of comparison between the contents of the abstracts and the contents of the articles were limitations. Future studies should address these issues and compare the quality of traditional and structured abstracts.