Interrater reliability of a tool to assess omission of prescription and inappropriate prescriptions in paediatrics.

Background Potentially inappropriate medication (PIM) and potential prescription omission (PPO) are common issues in pharmacotherapy in vulnerable populations. A first tool to assess PIM's and PPO's targeting pediatric populations: POPI «Pediatrics Omission of Prescriptions and Inappropriate Prescriptions¼ was created in 2014. Objective This study aimed to evaluate inter-rater reliability between healthcare professionals who apply POPI. Setting: Mother and child emergency ward of a university hospital. Method Twenty cases with or without PIM or PPO were identified in a previous retrospective PIM-PPO prevalence study on 15,973 patients. One doctor and one pharmacist, who participated in the creation of POPI tool, identified PIM and PPO ("gold standard response"). These cases were reviewed independently by eleven clinicians (generalists, pediatricians, pharmacists, residents), with no previous experience of this tool. Interrater agreement was calculated by using the Kappa agreement test. Main outcome measure: Inter-clinician agreement. Results A high level of agreement of PIM and PPO detection was recorded (PIM: median = 0.80; PPO: median = 0.71). Conclusion POPI demonstrated a good interrater reliability. This validation by many clinicians proves that POPI is a reliable tool. Other multicenter and prospective studies should be conducted to evaluate economical and clinical impacts of POPI.

Retrospective study of irrational prescribing in French paediatric hospital: prevalence of inappropriate prescription detected by Pediatrics: Omission of Prescription and Inappropriate prescription (POPI) in the emergency unit and in the ambulatory setting.

BACKGROUND AND OBJECTIVE: Pediatrics: Omission of Prescription and Inappropriate prescription (POPI) is the first detection tool for potentially inappropriate medicines (PIMs) and potentially prescribing omissions (PPOs) in paediatrics. The aim of this study was to evaluate the prevalence of PIM and PPO detected by POPI regarding prescriptions in hospital and for outpatients. The second objective is to determine the risk factors related to PIM and PPO. DESIGN: A retrospective, descriptive study was conducted in the emergency department (ED) and community pharmacy (CP) during 6 months. POPI was used to identify PIM and PPO. SETTING: Robert-Debré Hospital (France) and Albaret community pharmacy (Seine and Marne). PARTICIPANTS: Patients who were under 18 years old and who had one or more drugs prescribed were included. Exclusion criteria consisted of inaccessible medical records for patients consulted in ED and prescription without drugs for outpatients. PRIMARY AND SECONDARY OUTCOME MEASURES: PIM and PPO rate and risk factors. RESULTS: At the ED, 18 562 prescriptions of 15 973 patients and 4780 prescriptions of 2225 patients at the CP were analysed. The PIM rate and PPO rate were, respectively, 2.9% and 2.3% at the ED and 12.3% and 6.1% at the CP. Respiratory and digestive diseases had the highest rate of PIM. CONCLUSION: This is the first study to assess the prevalence of PIM and PPO detected by POPI in a paediatric population. This study assessed PIMs or PPOs within a hospital and a community pharmacy. POPI could be used to improve drug use and patient care and to limit hospitalisation and adverse drug reaction. A prospective multicentric study should be conducted to evaluate the impact and benefit of implementing POPI in clinical practice.

What can the Canadians and Americans learn from each other's health care systems?

Numerous papers have been written comparing the Canadian and US healthcare systems, and a number of health policy experts have recommended that the Americans implement their single-payer system to save 12-20% of its healthcare expenditures. This paper is different in that it assumes that neither country will undertake a significant philosophic or structural change in their healthcare system, but there are lessons to be learned that are inherent in one that could be a major breakthrough for the other. Following the model in Canada and in Western Europe, the USA could implement universal health insurance so that the 32.0 million (2015) Americans still uninsured would have at least minimal coverage when incurring medical expenditures. Also, the USA could use smart cards to evaluate eligibility and to process health insurance claims; these changes resulting in an estimated 15% reduction in US health expenditures without adversely effecting access or quality of care. Such a strategy would result in the eventual loss of 2.5 million white-collar jobs at hospitals, physician offices and insurance companies, a long-term economic gain. Only a few would agree with the statement that Canada already functions with a multi-payer reimbursement system as evidenced by (1) a federal-provincial, tax-supported plan, administered by each of the provinces, providing universal coverage for hospital and physician services and (2) roughly 60% of its residents receiving employer-paid health insurance benefits, underwritten primarily by investor-owned plans, that are less than effective to reimburse for pharmaceuticals, dental and other healthcare services. What could be learned from the USA and particularly from Western European countries is possibly implementing an approach, whereby at least upper-income Canadians could opt out of their federal-provincial plan and purchase private insurance coverage - being eligible for far more comprehensive "private" benefits for hospital, physician, pharmaceutical, dental and other healthcare services. Aside from generating billions of additional needed revenues from the private sector, it could (1) help eliminate long waits for non-emergent physicians' care by appointing newly minted specialists to their medical staffs; (2) offer prompt admissions for elective cases to "private" wings of hospitals; (3) increase available funding for what is currently an undercapitalized system; (4) enhance the system's sluggish operations; and (5) encourage more competition among various providers. Although such a two-tier approach, such as available in the USA and elsewhere, is politically dead on arrival in Canada today, private insurance being already legal and commonly available there. Interestingly, this recommended solution is utilized in most western European countries where there is a higher percentage than in Canada of public (versus private) funding of their total health expenditures. Because of various vested interests, attempts to implement any of the aforementioned proposals will undoubtedly result in considerable political rancor. There is greater likelihood, however, that the Canadians because their need to be more effective and efficient in their delivery of care, and their overall long-term fiscal outlook will agree to the further privatization of their healthcare system before the Americans will mandate universal access, use the smart card to process insurance eligibility and claims or will impose price controls on high-tech services and on pharmaceuticals. Copyright © 2016 John Wiley & Sons, Ltd.

With Additional Insurance Available, Why Are Not More Mental Health Services Being Provided?

Among the major objectives of the Mental Health Parity and Addiction Equity Act of 2008 and The Patient Protection and Affordable Care Act of 2010, often referred to today in political discussion as "Obamacare," was to significantly extend more health insurance benefits to those seeking mental health services. This commentary suggests that these recent legislative acts have accomplished little to date to enhance the delivery and the financing of additional mental health services because of the significant delays in rule making and other federal bureaucratic snafus, the numerous difficulties that the newly insured patients will experience in gaining access to qualified mental health personnel, and the cultural factors impinging on the hesitancy of the mentally ill to seek care from mental health professionals.

Patient falls in hospitals: an increasing problem.

Despite six decades of worldwide efforts that include publishing virtually hundreds of related epidemiological-type studies, there has been an increase (estimated to be 46% per 1000 patient days from 1954-6 to 2006-10) in the number of patient falls in hospitals and other health care facilities. These still occur most frequently near the bedside or in the bathroom, among mentally confused or physically impaired patients, and often involve those with greater comorbidity. The reasons that hospitals during the past half century have demonstrated a significant increase in patient falls per discharge or per patient days are numerous, are not completely surprising, and are certainly interrelated: improved accident reporting systems; on the average older, more impaired, more acutely ill, and more heavily sedated patients; and, less time spent by nursing personnel at the bedside. Most safety committees are not as effective as they should be, since they have difficulty in implementing a long-term, aggressive, facility-wide prevention program. Within that context, it may be worthwhile to discuss the advantages of nursing leadership rather than a representative of the facility's management staff to chair these safety committees.

Insufficient dollars and qualified personnel to meet United States mental health needs.

The American populace currently supports the need for providing additional mental health services for adolescents who frequently express anger and mood instability and maybe are at risk for major psychiatric disorders and behavioral problems; Vietnam, Iraqi, and Afghanistan veterans or military personnel still on duty diagnosed with posttraumatic stress disorder, depression, or other similar combat-related disabilities; the approximately 1 million prisoners currently incarcerated primarily because of substance abuse and needing medically related rehabilitative services; and senior citizens who experience dementia and depression and require improved therapeutics. The problems outlined herein are as follows: far too limited monies are being spent for mental health services (5.6% of total US expenditures for health or roughly one fifth of what is consumed for hospital care); effective therapies are often lacking; and there is a shortage of qualified mental health personnel except in upscale urban and suburban areas. Unfortunately, these problems are so immense that, even with enhanced prioritization of our available resources, they are still not entirely solvable. The American public may continue to impart lip service when attempting to respond to our nation's mental health needs or may decide to spend vastly more money for such care. The latter choice may not be forthcoming in the near future for various cultural-societal-clinical-fiscal reasons.

POPI (Pediatrics: Omission of Prescriptions and Inappropriate prescriptions): development of a tool to identify inappropriate prescribing.

INTRODUCTION: Rational prescribing for children is an issue for all countries and has been inadequately studied. Inappropriate prescriptions, including drug omissions, are one of the main causes of medication errors in this population. Our aim is to develop a screening tool to identify omissions and inappropriate prescriptions in pediatrics based on French and international guidelines. METHODS: A selection of diseases was included in the tool using data from social security and hospital statistics. A literature review was done to obtain criteria which could be included in the tool called POPI. A 2-round-Delphi consensus technique was used to establish the content validity of POPI; panelists were asked to rate their level of agreement with each proposition on a 9-point Likert scale and add suggestions if necessary. RESULTS: 108 explicit criteria (80 inappropriate prescriptions and 28 omissions) were obtained and submitted to a 16-member expert panel (8 pharmacists, 8 pediatricians hospital-based -50%- or working in community -50%-). Criteria were categorized according to the main physiological systems (gastroenterology, respiratory infections, pain, neurology, dermatology and miscellaneous). Each criterion was accompanied by a concise explanation as to why the practice is potentially inappropriate in pediatrics (including references). Two round of Delphi process were completed via an online questionnaire. 104 out of the 108 criteria submitted to experts were selected after 2 Delphi rounds (79 inappropriate prescriptions and 25 omissions). DISCUSSION CONCLUSION: POPI is the first screening-tool develop to detect inappropriate prescriptions and omissions in pediatrics based on explicit criteria. Inter-user reliability study is necessary before using the tool, and prospective study to assess the effectiveness of POPI is also necessary.

Leadership in academic health centers in the US: a review of the role and some recommendations.

The leadership of the US's most complex academic health centers (AHCs)/medical centers requires individuals who possess a high level of clinical, organizational, managerial, and interpersonal skills. This paper first outlines the major attributes desired in a dean/vice president of health affairs before then summarizing the educational opportunities now generally available to train for such leadership and management roles. For the most part, the masters in health administration (MHA), the traditional MBA, and the numerous alternatives primarily available at universities are considered far too general and too lacking in emotional intelligence tutoring to be particularly relevant for those who aspire to these most senior leadership positions. More appropriate educational options for these roles are discussed: (a) the in-house leadership and management programs now underway at some AHCs for those selected early on in their career for future executive-type roles as well as for those who are appointed later on to a chair, directorship or similar position; and (b) a more controversial approach of potentially establishing at one or a few universities, a mid-career, professional program (a maximum of 12 months and therefore, being completed in less time than an MBA) leading to a masters degree in academic health center administration (MHCA) for those who aspire to fill a senior AHC leadership position. The proposed curriculum as outlined herein might be along the lines of some carefully designed masters level on-line, self-teaching modules for the more technical subjects, yet vigorously emphasizing integrate-type courses focused on enhancing personal and professional team building and leadership skills.

Health management education: current alternatives.

The past several decades have witnessed a significant increase in the number of graduate programs in health management, either on campus or online. The alternative for a health professional to attending a graduate program on campus is to receive an MBA or MHA degree online. The current cost ranges from $13,600 to $78,000, with the more expensive online programs tied to graduate programs that are accredited by the Commission on the Accreditation of Healthcare Management Education and provide the names and qualifications of their faculty. The for-profit online programs have not been forthcoming to this author concerning their health management faculty or their curriculum. For the individual desiring more health management education who is unable to enroll, for family or financial reasons, in an on-campus program, the top-tier online programs seem like a worthwhile but is a relatively expensive option.

Commentary: something has to give. the question is, what?

A large facet joint cyst, the size of a walnut, at L5-S1 resulted in an "emergency" laminectomy at Asheville, North Carolina's Mission Hospitals on this 79-year-old active equestrian and retired healthcare consultant, who more than a half-century earlier was formally trained in hospital administration and medical economics. While as an inpatient, he reflected broadly about today's healthcare expenditures, utilization, and quality, and speculated on possible future remedies.

Hospital reimbursement incentives: is there a more effective option?--Part II.

As discussed in Part I of this article, hospital executives in Canada, Germany, and the United States manage their facilities' resources to maximize the incentives inherent in their respective reimbursement system and thereby increase their bottom line. It was also discussed that an additional supply of available hospitals, physicians, and other services will generate increased utilization. Part II discusses how the Patient Protection and Affordable Care Act of 2010 will eventually fail since it neither controls prices nor utilization (e.g., imaging, procedures, ambulatory surgery, discretionary spending). This article concludes with the discussion of the German multipayer approach with universal access and global budgets that might well be a model for U.S. healthcare in the future. Although the German healthcare system has a number of shortfalls, its paradigm could offer the most appropriate compromise when selecting the economic incentives to reduce the percentage of the U.S. gross domestic product expenditure for healthcare from 17.4% to roughly 12.0%.

Health management education in Europe and in the United States: a comparative review and analysis.

In Europe and in the United States, health management education and the role of health managers are patterned and consistent with how the country's healthcare system is organized, managed, and financed. In the United States, the fee-for-service, entrepreneurial dominated approach, resulting in health being one of the few remaining growth industries, has created a huge demand for additional health management education programs and managers. Therefore, universities finding themselves in an economic slump are attracted to establish health services administration programs (a North American term) since they require limited capital, continue to attract enrollment, and contribute to the "social good." In contrast, the European countries' healthcare systems provide universal access to care and strict, governmental fiscal control on healthcare expenditures. As a result, the American masters-level health manager model has not thrived there--although not willingly conceded is the fact that in Europe physicians continue to dominate the management ranks. After outlining a number of the current problems facing US health management education, this article focuses on: (1) a projected shuttering of the weaker American health management programs and the market for health managers being overly saturated (such as for lawyers now), because the US gross domestic product expenditures for health will decrease over the next two decades from the current level of 17.6% to be somewhat comparable to the 11.5% in Canada, France, and Germany; and (2) a projected increase in the enrollment among European health management programs for several reasons: (a) a huge spike in the demand for additional clinically oriented, health managers who can trade off concerns of cost versus quality; and (b) the constraints of most countries' statutory health insurance plans will become increasingly more evident so that privatization of healthcare services will become an option for those with above average incomes and, thereby, generate a demand for newly minted health managers similar to the US masters-level graduate.

Difficulties in consummating a meaningful hospital-physician collaboration.

Although there is a vast literature concerning the virtues of hospital-physician collaborative efforts, their actual performance to date in the United States according to rigorous research studies is far less than impressive. Hospitals are usually the party most interested in initiating such alignments, but physicians, as they respond to a patient's clinical needs, control almost all healthcare expenditures. Discussions between the parties have the potential of creating serious conflicts, primarily because of the lack of trust between physicians and hospital executives. The most frequent issues that arise are those relating to the sharing of ambulatory care revenues and who will be responsible for various clinical operations.

Why are ACOs doomed for failure?

Among the more ambitious parts of the Patient Protection and Affordable Care Act (2010) is the formation of Accountable Care Organizations (ACOs) that offer fiscal rewards when well-organized, integrated hospital-physician groups can improve quality of care and reduce the cost of Medicare expenditures. After studying the conceptual and operational issues, it is concluded herein that ACOs are in the long-haul doomed for failure since: 1) most hospitals and physicians have major difficulties in consummating tightly coordinated collaborative efforts; 2) providers historically have had a dismal track record in reducing cost, because of existing fee-for-service incentives; and 3) existing regulations do not provide sufficient fiscal rewards to assume the cost of starting an ACO and its possible operational risks.

Hospital reimbursement incentives: is there a more effective option?--Part I.

Based on the fiscal incentives inherent in a nation's hospital reimbursement methodology, it is highly predictable how the nation's healthcare executives will manage their organization's resources. The hospital data presented herein suggest that prospective reimbursement such as with DRGs in Germany and the United States encourages preadmission testing, more ambulatory care procedures, shorter average lengths of stay, and a greater number of employee hours per discharge. Payment on the basis of total patient days, such as in Canada, results in more acute care beds and more total days per 1000 persons, longer average lengths of stay, and less intensive use of personnel. But even when nations provide universal access, for various reasons those with mental illness and those who are indigent, poorly educated, and nonwhite use less healthcare services.

Privatization of hospitals: meeting divergent interests.

The United States, Germany, and the United Kingdom are experiencing a trend toward the privatization of hospitals--most frequently involving poorly positioned facilities that need: additional capital for replacement of plant and equipment; improved management systems to reduce the number of their nondirect patient care employees; and an aggressive physician recruitment effort. A number of these institutions might have been otherwise shut down, resulting in the loss of good paying jobs; however, these closures would have reduced the nation's total health care expenditures. The acquisition in the United States and Germany by investor-owned hospital corporations of major teaching institutions suggests that the for-profits have become an integral part of their country's health care delivery system. Privatization now even occurs within the egalitarian British National Health Service with the availability of private medical insurance, private hospitals, and private beds in public hospitals being managed by investor-owned groups. Being acquired by a for-profit is often a means to secure needed capital and is politically less fractious than closing down a marginally needed government-sponsored or a not-for-profit facility.

Hospital mergers: a panacea?

Hospital mergers in Europe and North America have been launched to scale down expenditure, enhance the delivery of health care and elevate quality. However, the outcome of mergers suggest that they neither generated cost savings nor improved the quality of care. Almost all consolidations fall short, since those in leadership positions lack the necessary understanding and appreciation of the differences in culture, values and goals of the existing facilities. In spite of these shortcomings, hospital mergers will continue to be pursued in order to improve market share, eliminate excess capacity, gain access to capital and enhance the personal egos of the organizations' leaders.

Leadership development in MHA programs: a response and commentary.

The transformation of healthcare from a relatively sheltered sector of the economy into one characterized by market competition and volatility has tested the values, abilities, and leadership strategies of healthcare executives. Changes in the scale and complexity of healthcare organizations and in provider reimbursement impose demands on executives that bear little resemblance to those of the past. In light of these challenges, health management programs are reassessing their responsibilities and capacities in the preparation of MHA graduates. Unfortunately, there is a lack of consensus on how students should be trained, advised, and mentored for leadership responsibilities. In our view, MHA programs can begin to address this problem through support of a balanced normative model for leadership training whereby classroom immersion in academic subjects is complemented by exposure to practice and experience. This model must be value-oriented, balancing business imperatives with traditional service ideals, and reality-oriented, balancing the teaching methods of theory and practice. In our view, MHA programs can begin to adapt to this model though student selection, curriculum reform, and involvement by practitioners and alumni.