Guidelines for the public health management of typhoid and paratyphoid in England: practice guidelines from the National Typhoid and Paratyphoid Reference Group.

OBJECTIVES: The Typhoid and Paratyphoid Reference Group (TPRG) was convened by the Health Protection Agency (HPA) and the Chartered Institute of Environmental Health (CIEH) to revise guidelines for public health management of enteric fever. This paper presents the new guidelines for England and their rationale. METHODS: Methods include literature reviews including grey literature such as audit data and case studies; analysis of enhanced surveillance data from England, Wales and Northern Ireland; review of clearance and screening schedules in use in other non-endemic areas; and expert consensus. RESULTS: The evidence and principles underpinning the new guidance are summarised. Significant changes from previous guidance include: • Algorithms to guide risk assessment and management, based on risk group and travel history; • Outline of investigation of non-travel cases; • Simplified microbiological clearance schedules for cases and contacts; • Targeted co-traveller screening and a "warn and inform" approach for contacts; • Management of convalescent and chronic carriers. CONCLUSIONS: The guidelines were launched in February 2012. Feedback has been positive: the guidelines are reported to be clear, systematic, practical and risk-based. An evaluation of the guidelines is outlined and will add to the evidence base. There is potential for simplification and consistency between international guidelines.

Modeling the future workforce of obstetrics and gynecology.

OBJECTIVE: To examine the current supply and distribution of obstetrician-gynecologists and project future supply under various scenarios. METHODS: A discrete actuarial supply model was developed, and practice patterns were analyzed. Supply projections under different scenarios, distributions, and practice profiles were examined. RESULTS: Women are expected to become the majority of practitioners by 2014. Continuation of current residency output will result in slow to no growth in obstetrician-gynecologist-to-female population ratios over the next 20 years. A minor (10%) reduction in specialty training would slow specialty growth over the next decade, followed by a slight reduction in supply. Services provided chiefly involve ambulatory reproductive health care, pregnancy, and surgical correction of conditions specific to the female genitourinary system. Even though the proportion of deliveries performed by midwives has increased and family practitioners have maintained their share, obstetrician-gynecologists provide the vast majority of obstetric care and virtually all services for perinatal complications. Generalist services represent relatively minor aspects of their practices. Care of the aged female population is highly fragmented among specialties; more than 50% of all aged Medicare beneficiaries who saw an obstetrician-gynecologist at least once failed to receive a majority of services from any one physician specialty. CONCLUSION: On the basis of trends in patient demographics and care patterns, obstetrician-gynecologists must resolve whether to provide more generalist office-based care, especially to the rapidly growing older female population, or to invest more intensively in surgical specialty care. The specialty's unique contributions to women's health should influence this decision.

Provider workforce model for regional TRICARE networks.

A model is presented that can estimate the total number and specialty mix of health care providers needed to serve a defined population. Military commanders in charge of TRICARE regions, known as "lead agents," can use this model to estimate the provider workforce composition needed to serve their area. Physician staffing patterns front managed-care organizations help define the provider-to-patient proportions on which this model is based. Data needed to perform the model's computations are derived from the regional enrolled beneficiary population and the number of active duty providers. As a result, the model provides an estimate of the number and type of civilian providers that need to be contracted to adequately serve the regional military network.

Retraining physicians for primary care. A study of physician perspectives and program development.

OBJECTIVE: To determine the number and kinds of programs that medical schools and managed care organizations offer or plan to offer to retrain physician specialists to practice primary care medicine and to discover physicians' attitudes toward such retraining. DESIGN: A survey was mailed in 1994 to all 126 medical schools and the 19 largest US managed care organizations to collect detailed information about existing and potential retraining programs. Physicians' attitudes toward retraining were elicited from participants in 3 geographically diverse focus groups. Selected specialists were polled through the national survey of the American Medical Association's Socioeconomic Monitoring System to ascertain the demand for retraining. RESULTS: The majority of institutions contacted perceived a need for retraining, but few programs had been established. Programs being "considered" varied widely in duration, class size, target audience, accreditation, and projected training settings. Although unenthusiastic about retraining, physicians preferred programs that would expand their patient base, maintain the practice population, be inexpensive and close to home, and provide hands-on training in the eventual practice environment. Physicians also preferred a goal-oriented, part-time retraining program in a large group practice or managed care setting that would allow them to practice their specialty while retraining. Few planned or existing programs incorporate many of these features. The most likely candidates for retraining are subspecialty physicians who currently provide some primary care and are employed by a medical plan. CONCLUSIONS: Despite efforts by those who perceive that a need for more generalist physicians is stimulating interest in retraining specialists and subspecialists to provide primary medical care, physician interest and program availability remain low, and programs under development are not being designed to attract those who may seek retraining. This situation is probably fortuitous, because changed perceptions about the adequacy of the generalist physician workforce since the beginning of this study have diminished the call for retraining.

Competency in health care management: a training model in epidemiologic methods for assessing and improving the quality of clinical practice through evidence-based decision making.

This article describes a training model that focuses on health care management by applying epidemiologic methods to assess and improve the quality of clinical practice. The model's uniqueness is its focus on integrating clinical evidence-based decision making with fundamental principles of resource management to achieve attainable, cost-effective, high-quality health outcomes. The target students are current and prospective clinical and administrative executives who must optimize decision making at the clinical and managerial levels of health care organizations.