Addressing issues of maldistribution of health care workers.

INTRODUCTION: The maldistribution of health care workers is a near-universal problem, particularly in developing countries. Shortages have become most critical over the past 2 decades with both out-migration of health care workers from developing to developed countries, and intra-country disparities between urban centres and rural regions. A variety of solutions have been proposed and tried, but in recent years the problem has become increasingly serious. PROGRAMME DESCRIPTION: Over the past 15 years, we have conceptualised and implemented a programme directed at the re-supply of rural physicians to our own state, Illinois, which was recently ranked as low as sixth worse in the US with regard to physician manpower shortages in rural areas. More recently, this programme has been expanded to include other health care workers where there are equivalent shortages in health services accessibility, and the entire programme is now designated as the National Center for Rural Health Professions. PROGRAMME EVALUATION: Currently, the physician programme enjoys a 65% to 70% success rate in terms of the return of physicians to rural communities; a success largely due to the unique selection process, training, and the close relationship between students and faculty. Here, we describe this programme in detail, in the hope that elements of this somewhat unique programme may be "exportable".

Cycle of child sexual abuse: links between being a victim and becoming a perpetrator.

BACKGROUND: There is widespread belief in a 'cycle' of child sexual abuse, but little empirical evidence for this belief. AIMS: To identify perpetrators of such abuse who had been victims of paedophilia and/or incest, in order to: ascertain whether subjects who had been victims become perpetrators of such abuse; compare characteristics of those who had and had not been victims; and review psychodynamic ideas thought to underlie the behaviour of perpetrators. METHOD: Retrospective clinical case note review of 843 subjects attending a specialist forensic psychotherapy centre. RESULTS: Among 747 males the risk of being a perpetrator was positively correlated with reported sexual abuse victim experiences. The overall rate of having been a victim was 35% for perpetrators and 11% for non-perpetrators. Of the 96 females, 43% had been victims but only one was a perpetrator. A high percentage of male subjects abused in childhood by a female relative became perpetrators. Having been a victim was a strong predictor of becoming a perpetrator, as was an index of parental loss in childhood. CONCLUSIONS: The data support the notion of a victim-to-victimiser cycle in a minority of male perpetrators but not among the female victims studied. Sexual abuse by a female in childhood may be a risk factor for a cycle of abuse in males.

Quality of life, health care utilization, and costs among women undergoing hysterectomy in a managed-care setting.

OBJECTIVE: We compared quality of life, utilization, and costs for women undergoing elective abdominal, laparoscopically assisted vaginal, or vaginal hysterectomy within a managed-care organization. STUDY DESIGN: A prospective study of 287 women who underwent an elective hysterectomy was performed. RESULTS: Patients undergoing a vaginal hysterectomy reported returning to normal activity levels sooner and had more favorable quality-of-life scores than did those undergoing laparoscopically assisted vaginal hysterectomy or abdominal hysterectomy. Laparoscopically assisted vaginal hysterectomy was often nearly as favorable as vaginal hysterectomy, particularly at 28 days after the operation, whereas the abdominal hysterectomy group consistently reported the poorest postoperative quality-of-life scores. No significant differences were noted in utilization or costs in the 60-day preoperative period, whereas hospitalization and postoperative costs were highest among the abdominal hysterectomy group and lowest for those undergoing a vaginal hysterectomy. CONCLUSIONS: Vaginal hysterectomy resulted in better quality-of-life outcomes and lower utilization and costs compared with laparoscopically assisted vaginal or abdominal hysterectomy.

Assessment and treatment of geriatric depression in primary care settings.

OBJECTIVE: To examine primary care physicians' practices relating to the diagnosis and management of geriatric depression, attitudes regarding responsibilities for and barriers to management, self-assessments of their needs in providing this care, and physician characteristics that correlate with attitudes and practices. DESIGN: Descriptive and analytic needs assessment. SETTING: A midwestern city and surrounding county and the suburb of another midwestern city. MEASUREMENTS: A self-administered survey consisting mainly of close-ended, Likert scale questions. PARTICIPANTS: One hundred forty-one family physicians and general internists (53.2%) responded. Respondents were 75.4% male and 50.8% general internists and ranged in age from 29 to 75 years (mean, 43 years; SD, 11 years). RESULTS: No standard test to screen for depression was used by 66.7% of respondents. The 2 most common laboratory studies ordered were thyroid studies (41.1%) and chemistry panels (37.6%). Selective serotonin reuptake inhibitors were most commonly prescribed for depression (53.2%). Although 98.6% of respondents agreed that treatment of depression in elderly patients was important, 29.0% reported that depressed elderly patients frustrated them, and 24.2% were too pressured for time to routinely investigate depression in the elderly. The most frequently identified needs in caring for these patients were increased time with patients (97.1%); increased reimbursement for counseling (87.8%); greater emphasis in medical training on the link between physical and mental health (85.6%); improved patient compliance with treatment (84.3%); and more training and attention to depression in residency (82.1%). In general, family physicians were more active and positive in their approach toward geriatric depression. CONCLUSIONS: Potential interventions to improve the diagnosis and management of geriatric depression include the following: use of screening instruments in a more efficient and timely manner; increased reimbursement for counseling of patients; more educational programs at the undergraduate, graduate, and continuing medical education levels; and clinical practice guidelines specific to geriatric depression.

Alternative approaches to hysterectomy: clinical and economic implications for managed care.

Hysterectomy is one of the most frequently performed surgical procedures in the United States. Through advances in pharmacological and surgical technologies, opportunities now exist for converting selected hysterectomies from the traditional abdominal approach to vaginal or laparoscopically-assisted vaginal procedures. Such conversions may lead to diminished operative morbidity, fewer hospital days, a decreased period of convalescence, and the opportunity for cost savings. This paper reviews current clinical thought on the subject and considers the economic effect for providers of care.

Payment mechanism and patterns of use of medical services: the example of hypertension.

This study explores the relationship between the use of medical services by hypertensive patients and mechanisms for payment within a single primary care practice. Three payment mechanisms were explored: public assistance, a capitated health maintenance organization (HMO), and fee-for-service. Patterns were examined across reimbursement type for the following variables: age, sex, visit reason, number of visits, medications, tests ordered, referrals made, and recommendations for follow-up visits. Illness severity was controlled in two ways: (1) by the study being focused on one diagnosis--mild to moderate hypertension, and (2) by concurrent chronic illnesses being enumerated and included in the analysis. Medical visits to the physician were examined over a 2-year period for 25 to 30 patients randomly sampled from each of the three payment mechanisms. Statistically significant differences were found for patient behaviors (total number of patient visits) and physician behaviors (number of medications and recommendations for revisits). The highest visit frequency was found for those on public assistance, followed closely by those covered by an HMO, and more distantly by those choosing fee-for-service. In a climate of cost consciousness, further study is needed to explore the impact of reimbursement mechanisms on the use of health care services.

The Health Security Partnership: an equitable, pragmatic, and passable national health program.

The Health Security Partnership is an equitable, pragmatic, and legislatively passable health program. The proposed reform of the health care system is based on realistic principles designed to promote access and produce changes that will restrain costs while delivering quality health services. Among the principles on which the program is built are full and equitable access to health care, along with abolition of the "separate but less equal" system called Medicaid, and a national-state administration that requires uniform standards of core benefits across state lines combined with differing patterns of state administration. States will be able to expand benefits as appropriate. Enforceable cost-containment measures are seen as essential corollaries to universal access. Biennial state and national budgets, prospective global hospital and other institutional budgets, relative-value physician fee schedules, and controls on prescription drug prices are essential parts of the program. The plan provides for evolutionary change and orderly transition to a reformed delivery system. The retention of free choice of physicians and simplified administration with substantial consumer choice in decision-making offer the hope of sharply reduced financing cost increases combined with the growth in delivery of quality medical care.

Strategies to avoid unnecessary cesarean sections.

Because there is a 35 to 50 percent incidence of false-positive prediction of fetal compromise on fetal heart-rate monitoring patterns, many unnecessary cesarean sections are performed. To reduce the number of unnecessary cesarean sections, the physician is urged to consider the following: (1) fetal heart-rate monitoring is associated with higher rates of cesarean sections than in those not monitored; (2) only high-risk patients should be monitored provided the low-risk patient is at term, with a normal-sized infant, and does not convert to a high-risk patient while in labor; (3) maintenance of variability is a better predictor of absence of acidosis than is fetal scalp pH; (4) fetal scalp stimulation by firm digital pressure or gentle nontraumatic clamping of scalp tissue or acoustic stimulation obviates the need for fetal scalp pH confirmation of acidosis in 50 percent of cases; (5) monetary considerations may unconsciously lead to increased cesarean sections, since insurance companies remunerate at a higher level for those as compared with vaginal deliveries; and (6) more patients with prior cesarean section should be given a trial of labor, since the initial reason for cesarean section often is not a recurring one and many could successfully be delivered vaginally. Ultimately there is a risk inherent in any decision regarding method of delivery. The patient must understand this risk and share in the decision-making process as a knowledgeable person, aware of the limitation of her physician.

Patients' views of the medical education setting.

The results of a survey of 1,334 patients at three community health centers operated by the University of Illinois College of Medicine at Rockford are presented and discussed. The research was designed to begin to obtain a better understanding of the patient's views on the quality of care and medical students in the medical education setting. Patients in the study reported being attracted to the educational site for the same reasons they would go to a private physician, that is, location, advice of a friend, or dissatisfaction with their previous doctor. They also reported satisfaction with care in general and with the specific components of care at the health centers. However, the patients expressed different views of the medical student's role, and there were differences in the patients' preferences for a student or a faculty physician depending on their medical problem or condition. These views of the student's role and the patients' preferences of physicians were found to be related significantly to the patient's age, the patient's perception of his primary source of medical care, the patient's evaluation of the effect of medical schools on health care, and the patient's level of satisfaction with the care received.