Development and national consensus finding on patient-centred high stakes communication skills assessments for the Swiss Federal Licensing Examination in Medicine.

OBJECTIVE: To describe and evaluate a consensus finding and expert validation process for the development of patient-centred communication assessments for a national Licensing Exam in Medicine. METHODS: A multi-professional team of clinicians and experts in communication, assessment and role-play developed communication assessments for the Swiss Federal Licensing Examination. The six-month process, informed by a preceding national needs-assessment, an expert symposium and a critical literature review covered the application of patient-centred communication frameworks, the development of assessment guides, concrete assessments and pilot-tests. The participants evaluated the process. RESULTS: The multiple-step consensus process, based on expert validation of the medical and communication content, led to six high-stakes patient-centred communication OSCE-assessments. The process evaluation revealed areas of challenge such as calibrating rating-scales and case difficulty to the graduates' competencies and integrating differing opinions. Main success factors were attributed to the outcome-oriented process and the multi-professional exchange of expertise. A model for developing high stakes patient-centred communication OSCE-assessments was derived. CONCLUSIONS: Consensus finding was facilitated by using well-established communication frameworks, by ensuring outcome-orientated knowledge exchange among multi-professional experts, and collaborative validation of content through experts. PRACTICE IMPLICATIONS: We propose developing high-stakes communication assessments in a multi-professional expert consensus and provide a conceptual model.

The economic impact of alternative cardiac care unit treatment practices.

A case-mix strategy was used with hospital chart-abstract data from New Jersey to estimate the hypothetical savings in the cost of Cardiac Care Unit (CCU) care in the state that would result from the state-wide implementation of the following five policies: limiting uncomplicated Acute-Myocardial Infraction (AMI) patients to seven days of hospitalization; treating uncomplicated AMI patients at home; using the CCU only for diagnoses for which it is widely accepted as effective; tightening CCU admission criteria; and tightening CCU discharge criteria. The selection of these policies was based on a review of the CCU literature and on empirical data from the New Jersey CCU system. The case-mix strategy involved; the creation and categorization of a list of diagnoses which are eligible for CCU treatment; the selection of a sample of hospitals for study; and the estimation of the savings which would result from the implementation of the hypothetical CCU policies throughout the state. The estimated savings were substantial compared to the total cost of CCU care in New Jersey, stressing the need for further investigation of the cost-effectiveness of current CCU treatment practices. In addition, the case-mix method used in this study is recommended for bringing considerations of the cost-effectiveness of clinical practice into public policy debates on the regulation of medical services.

Adjusting planning guidelines for cardiac-care units.

The principal concern of this paper is the development of procedures for adjusting the criteria currently being used for federally-legislated health planning activities. These procedures would enable the planner to account for the demographic, geographic and health-system conditions which cause variations in the need for health-care services in local communities. A case-mix method, hospital chart abstract data and demographic, geographic and health-system data from New Jersey were used to: create a list of diagnoses eligible for treatment in a Cardiac-Care Unit (CCU): select a sample of hospitals for study, and conduct a step-wise regression analysis of CCU utilization in these hospitals. It was concluded that CCU utilization was affected by factors such as the in-hospital availability of CCu beds, the type of hospital, CCU-patients' clinical severity, and the availability of ambulances and mobile intensive care units. Procedure for adjusting planning criteria to account for local conditions have yet to be developed. However, a method for using the types of results presented in this paper to develop such adjustment procedures was presented and illustrated. It is recommended that this method be used to create such adjustment procedures for the planning criteria for all hospital services and hence to assist Health Systems Agencies in rationalizing the distribution of our hospital care.

Self-absorption of tritium betas in metal tritide particles.

Inhaling metal tritide particles is a potential occupational hazard. The radiation dose to tissue from tritide particles depends on their solubility and retention in the body. In each tritide particle, a portion of the beta particles from decay of tritium is absorbed by the metal matrix and therefore cannot contribute to absorbed radiation dose to tissue. A theoretical model for estimating the self-absorption of tritium betas in spherical metal tritide particles is presented. Numerical calculations are made with this method for titanium, zirconium, and erbium particles from 0.5 to 50 microm in diameter. The tritium spectrum is divided into energy groups to facilitate estimation of the energy that escapes the particle for dose calculations. Our results show considerable absorption of beta particles and their energy, even for respirable particles smaller than 5 microm. Limited experimental data of self-absorption for titanium and zirconium tritides supported the theoretical calculation. It is concluded that the self-absorption factors should be required for counting tritide particle samples as well as for estimating absorbed radiation dose to tissue.

Managing for technology to improve service.

What challenges today's healthcare executive is deciding what new technologies to purchase and exactly when to do so. Scan the marketplace for them--both in the healthcare field and in industry.

Strategic uses of teleradiology.

The most frequently cited benefits of image communications systems (teleradiology) are: (1) a reduction in the travel time of radiologists, and (2) an improvement in access to services, especially in rural areas. The benefits of teleradiology services for hospitals are, however, potentially much greater. Teleradiology services could alter the competitive positions of organizations in the market for imaging services and change the nature of the competition. In this article we examine how a small community hospital and a large referral hospital might each use teleradiology strategically to improve their respective competitive positions.

Competitor analysis for imaging services.

Managers of radiology and imaging services need to continually question their assumptions about competitors, particularly in highly competitive markets. The systematic collection of information about a competitor's future goals, current strategies, assumptions held and capabilities can improve the accuracy of predictions of a competitor's future behavior. The resources devoted to a competitor analysis should depend on the level of risk which a manager's organization faces. Interviews with selected professionals involved in the day-to-day operations of radiology and imaging services are the most important source of information, but published and unpublished information available to the public can provide essential background information and corroborate the information gained through interviews.

A case-mix method for developing health planning criteria for hospital services.

The principal concern of this article is the inadequacy of the planning criteria currently being used by existing federally funded health planning agencies. A case-mix method was created for developing appropriate criteria. Chart-abstract data from New Jersey were used to create a list of those diagnoses eligible for treatment in the cardiac care unit (CCU), select a sample of hospitals for study and analyze the relationship between CCU bed need and CCU clinical practice. It was shown that existing bed-need criteria for CCU planning represent current CCU clinical practice patterns, which are probably not cost effective. The method was also used to develop empirical values of these criteria, which do represent cost-effective practice. It is recommended that the method be used to strengthen and update continuously all hospital-service need criteria used in current planning activities, including Plan Development and Certificate of Need Review.

Developing a competitive advantage in the market for radiology services.

This article describes how managers of outpatient diagnostic radiology services can develop a competitive advantage by increasing the value of services to patients and referring physicians. A method is presented to identify changes to services that increase their value. The method requires the definition of the "value chains" of patients and referring physicians. Particular attention is paid to the use of information systems technology to suggest and implement service changes. A narrow range of health services was selected because the approach requires a detailed understanding of consumers and how they use services. The approach should, however, be examined carefully by managers seeking to develop a competitive advantage for a wide range of health services.

Innovation in hospital plans.

Strategic planning, competition, marketing and the use of sophisticated analytic techniques are constantly being called essential to the survival of hospitals. The authors found no evidence in a sample of plans that these concepts and techniques are being widely adopted.

Catecholamine-sensitive adenylate cyclase in the white perch (Roccus americanus) retina: evidence for beta-adrenergic and dopamine receptors linked to adenylate cyclase.

We have examined the catecholamine-sensitive adenylate cyclase in the retina of the white perch (Roccus americanus). Both dopamine and the beta-adrenergic agonist isoproterenol stimulate cyclic AMP accumulation in this retina, but serotonin, an indoleamine, and phenylephrine, an alpha-adrenergic agonist, had no effect. The stimulation of adenylate cyclase by isoproterenol is more potent and effective than that of dopamine. The effects of dopamine and isoproterenol are mediated via independent dopamine and beta-adrenergic receptors. Haloperidol, a dopamine antagonist, blocks the stimulatory effect of dopamine but not of isoproterenol. Conversely, propranolol, a beta-adrenergic antagonist, blocks the stimulatory effect of isoproterenol but not of dopamine. The effects of dopamine and isoproterenol are not additive. In fractions of purified horizontal cells we found evidence for dopamine receptors linked to adenylate cyclase but did not find evidence for the presence of cyclase coupled beta-adrenergic receptors. The cellular location of the beta-adrenergic receptors is unknown. Our findings demonstrate the existence of both beta-adrenergic and dopamine receptors coupled to adenylate cyclase in the white perch retina. However, we did not find either epinephrine or norepinephrine, endogenous ligands of the beta-receptor, to be present in retinal extracts subjected to HPLC.