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The article presents consensus paper regarding legal healthcare issues in caring for pressure ulcer patients prepared by the International Expert Wound Care Advisory Panel in the U.S. It notes that patients with pressure ulcers carry heavy burden due to human suffering and expensive health care costs. It states that the consensus paper is created to promote legal issue awareness on pressure ulcers and provide medical guidance to health care providers.

Acknowledging the extreme risk COVID-19 poses to humans, this paper attempted to analyze and compare case fatality rates, identify the existence of learning curves for COVID-19 medical treatments, and examine the impact of vaccination on fatality rate reduction. Confirmed cases and deaths were extracted from the "Daily Situation Report" provided by the World Health Organization. The results showed that low registration and low viral test rates resulted in low fatality rates, and the learning curve was significant for all countries except China. Treatment for COVID-19 can be improved through repeated experience. Vaccinations in the U.K. and U.S.A. are highly effective in reducing fatality rates, but not in other countries. The positive impact of vaccines may be attributed to higher vaccination rates. In addition to China, this study identified the existence of learning curves for the medical treatment of COVID-19 that can explain the effect of vaccination rates on fatalities. [ABSTRACT FROM AUTHOR]

In the wake of COVID-19, mental health providers and treatment programs are adapting rapidly to the challenges in engaging people and delivering treatment with limited guidance. This paper will explore the challenges associated with delivering treatment within coordinated specialty care (CSC) programs for people with first episode psychosis. Suggestions for treatment will take into consideration experiences with stress, changes to the pursuit of work and school, and increased time spent with families. Drawing on the experience of several CSC programs in the United States, Israel, and China, we describe the impact and modifications to the core treatment elements in CSC including medication, family interactions, supported employment and education, individual therapy, peer support and the way they are delivered. The paper includes recommendations based on experiences from CSC programs to help staff members, participants, and family members better identify, prepare, cope and respond to the unique new challenges and suggests modifications that can be made during various stages of the coronavirus pandemic. [ABSTRACT FROM AUTHOR]

The article reports that American Health care system wastes about 750 million U.S. dollars in unnecessary medical procedure and paper works. It highlights the utmost need to improve quality of medical care provided by medical institutions in the U.S. to the patients for their satisfaction in medical facilities. It mentions that the patients' grievances can be solved through greater use of electronic health records and provision of delivering evidence based care to patients.

This paper is a statement of the American Geriatrics Society's (AGS) core policy priorities and the Society's positions on federal programs and policies that support older Americans as articulated to the new administration. Among the AGS priorities discussed in this paper are health reform, Medicare, and Medicaid. The AGS is committed to leveraging its expertise to inform regulatory and legislative policy proposals. [ABSTRACT FROM AUTHOR]

A trauma-informed, thematic analysis that identified stress-related themes evident in 39 personal abortion narratives from the Tennessee Stories Project in the United States is presented in this paper. Using the Braun and Clarke model of thematic analysis, guided by the trauma-informed social work framework, researchers examined these narratives to identify stress related themes. Findings: An overall theme of stress and traumatic stress was found to be present throughout the abortion narratives. These themes were categorized into subthemes, including: (a) existing life stressors preceding the abortion experience, (b) stressors while trying to access abortion services, (c) stressors while obtaining abortion services, and (d) stressors arising after the procedure. Applications: These results suggest that stress and traumatic stress were reflected in these abortion narratives throughout the abortion seeking experience. This finding supports the need for social work practice responses that are designed to address and eliminate stress during the process of seeking and obtaining an abortion in the United States. A trauma-informed framework is recommended for guiding social work education about abortion, social worker interactions with clients who are seeking abortions, and the development of abortion policy in the United States in order to better align the abortion seeking experience with the principles of trauma-informed care. [ABSTRACT FROM AUTHOR]

This paper studies the effect of incentive regulation on health care. In the context of incentive-based health contracts, which might also introduce an incentive for the providers simply to report better treatment outcomes, evaluation of treatment using the information supplied by the providers (reported output) could be problematic. The systematic error on the output report is called providers' gaming behavior. This paper develops a general method for decomposing the effect of incentive-based contracts on performance into the true effect, which is the result of clinicians' improved effort induced by the contract, and the gaming effect, which is due to the change in the providers' reporting practice. The method follows the essence of linear structural relation (LISREL) models, and the true treatment output is modeled using a latent variable. Various output measures can be included in the structural evaluation model, but objective measure(s) (output measures not affected by providers' potential gaming) must be constructed based on available information to identify gaming through its correlation with the reported measures. The strengths of this method are that information from more than one output measure can be used, no monitoring system is required, and the construction of a gold-standard measure is not necessary. This method is applied to evaluate the impact of Maine's performance-based contracting on its public providers' substance-abuse services. Evidence of gaming is found in Maine's system, which remains robust in most of the sensitivity analyses. The methodology developed here can be used to evaluate the impact of a broad range of incentive-based contracts. [ABSTRACT FROM AUTHOR]

Heart failure is one of the leading causes of hospitalizations in the United States, with >1 million admissions yearly and a 25% risk of readmissions within 1 month. In order to assist clinicians, we provide an update of the heart failure bibliography that was published in Pharmacotherapy in 2008, which followed the original bibliography published in 2004. A significant number of clinical trials and observational studies have been conducted since the early 1980s to guide management of heart failure patients. Major advances have occurred in the past 10 years, and our understanding of the diagnosis, prevention, and management of heart failure has evolved substantially during this time period. Specific areas of this review include heart failure risk factors, management of comorbid conditions, acute heart failure management, chronic heart failure management, advanced heart failure, device therapy, lifestyle modification, and medication and therapy management, including medication adherence. Key consensus guidelines and statements are also included. This bibliography of key heart failure papers aims to provide clinicians and their trainees with a valuable clinical reference resource and teaching tool that may be used to optimize the care of patients with heart failure. [ABSTRACT FROM AUTHOR]

Secure messaging, or "e-visits," between patients and providers has sharply increased in recent years, and many hope they will help improve healthcare quality, while increasing provider capacity. Using a panel data set from a large healthcare system in the United States, we find that e-visits trigger about 6% more office visits, with mixed results on phone visits and patient health. These additional visits come at the sacrifice of new patients: physicians accept 15% fewer new patients each month following e-visit adoption. Our data set on nearly 100,000 patients spans from 2008 to 2013, which includes the rollout and diffusion of e-visits in the health system we study. Identification comes from difference-in-differences estimates leveraging variation in the timing of e-visit adoption by both patients and providers. We conduct several robustness checks, including matching analyses and an instrumental variable analysis to account for possible time-varying characteristics among patient e-visit adopters. This paper was accepted by Chris Forman, information systems. [ABSTRACT FROM AUTHOR]

In the United States, the past decade has seen rapid growth in treatment centers providing specialty care to patients with eating disorders. Much of this growth has been in higher levels of care, including hospital‐based and residential treatment. Despite this expansion, there remains lack of agreement regarding the most important components of care, such as staff training or specifics of treatment delivery. Additionally there is no consensus on how best to assess outcome and compare performance across programs. This leaves patients, families, public and private insurance programs, and policy makers with limited information to help facilitate treatment decisions. The present paper considers implications of these changes in the eating disorder treatment landscape and examines two ideas that, if implemented, may enhance the quality of eating disorder care. First, we explore the proposal to develop a network of centers of excellence in eating disorder treatment and the value this may have for improving overall treatment quality. This idea was discussed at an expert meeting held at SAMSHA in 2017 regarding issues important to the field following passage of the 21st Century Cures Act. Second, we consider the potential utility of a study using the Delphi method to promote expert consensus regarding clinical outcome assessments. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this paper is to examine relationships between internationally educated nurses’ (IENs’) performance in a registered nurse competency assessment process and the outcomes of their nursing registration applications. Assessments of nursing practice competencies, IEN applicant characteristics and registration outcomes were explored.Design/methodology/approach This is a secondary statistical analysis of a subset of IEN application data from a previous study in combination with assessment data from an additional database. Application data between 2008 and 2011 were analyzed using univariate/bivariate analyses and regression models to explore the relationship of performance in the assessment process and outcomes of the registration process.Findings Competency categories IEN applicants had difficulties with (from least to most) were Professional Responsibility and Accountability, Ethical Practice, Self-Regulation, Service to the Public, Knowledge-Based Practice: Specialized Body of Knowledge and Knowledge-Based Practice: Competent Application of Knowledge. IENs educated in the UK and USA had the highest scores and odds of meeting competencies. Applicants educated in India and Asia had lower scores and odds ratios. All national entry-to-practice examination and registration eligibility competencies were significantly related to registration outcomes. Applicants passing the exam had higher competency scores while applicants ineligible for registration had lower competency scores.Research limitations/implications Limitations include integrity of data extracted from active databases, IEN motivation to complete the RN registration process and conversion of assessment scales for research analysis.Originality/value Results inform regulation policies that improve IEN registration processes and may be informative to regulators, assessment centers, educational institutions and IENs. [ABSTRACT FROM AUTHOR]

Background: This paper aims to contribute to the discussion about patient‐centred care in surgery. It is contended here that the paradigm shift towards patient‐centred decision‐making in health care does not mean that patient values alone (or those of their proxies) should, uncritically, be the lead decision makers in determining surgical care. Methods: In support of that contention, three clarifications to our conception of autonomy will be offered. Results: First, autonomy may not be best positioned as the lead principle guiding healthcare decision‐making. Second, arguably, our traditional understanding of autonomy, as it might be applied to health care, is incomplete. Third, where autonomy is vested is contentious, and proxy decision makers can further complicate the decision‐making process. Conclusion: It will be argued that an approach of inclusive, non‐coercive and reflective dialogue seeking a consensual decision amongst all those affected is more appropriate for moral decision‐making in surgery. This dialogue is set in the actual reality of the patient's illness. During the discourse, each participant has equal rights to contribute and to be heard, equal duties not to coerce and equal co‐responsibilities to share the perspectives of others in the discourse, with an aim to reach consensus. [ABSTRACT FROM AUTHOR]

Abstract: This article explores the complicated and often‐contradictory notions of choice at play in complex care management (CCM) programmes in the US healthcare safety net. Drawing from longitudinal data collected over two years of ethnographic fieldwork at urban safety‐net clinics, our study examines the CCM goal of transforming frequent emergency department (ED) utilisers into ‘active’ patients who will reduce their service utilisation and thereby contribute to a more rational, cost‐effective healthcare system. By considering our data alongside philosopher Annemarie Mol's (2008) conceptualisation of the competing logics of choice and care, we argue that these premises often undermine CCM teams' efforts to support patients and provide the care they need – not only to prevent medical crises, but to overcome socio‐economic barriers as well. We assert that while safety‐net CCM programmes are held accountable for the degree to which their patients successfully transform into self‐managing, cost‐effective actors, much of the care CCM staff provide in fact involves attempts to intervene on structural obstacles that impinge on patient choice. CCM programmes thus struggle between an economic imperative to get patients to make better health choices and a moral imperative to provide care in the face of systemic societal neglect. (A virtual abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA). [ABSTRACT FROM AUTHOR]

The article discusses results of a study that examines the crowding measures in the emergency department (ED), with comparison in conceptual validity and foundation. The methods of the study are described, including the review of medical care and health care citation databases. The study showed that clinical opinion is the least used type of crowding measure, while numerical counts of patients and process times are the most commonly used. It concludes by citing the potential of time intervals and patient counts as measuring tools.

Purpose - Implicit bias is the application of an unconscious attitude or belief; in the clinical setting, a provider's perception of a patient, based upon perceived race or ethnicity, is hypothesized to affect clinical decisions, provider-patient interactions and patient health. The purpose of this paper is to provide a brief synopsis of and critique the relevant works over the past 15 years while highlighting the strengths of this body of literature. Design/methodology/approach - A MEDLINE search, from 2000 to 2015, using the terms "implicit bias," "unconscious bias" and "aversive racism" was performed. US-based studies investigating the effect of racial or ethnic implicit bias on the clinical encounter or patient outcomes were assessed. In total, 15 articles were eligible for review. Findings - Despite well-reasoned hypotheses that racial/ethnic bias negatively affects patient care, this review found mixed results. Largely, studies showed that US-providers hold an anti-black implicit bias negatively affecting patient-provider communication and patient satisfaction. But studies have not shown that this bias consistently negatively affects diagnosis and treatment regimens of black patients in comparison to white patients. There is a significant dearth of implicit bias literature addressing the care of other patient groups of color. Originality/value - This review of the recent literature challenges the black-white dichotomy of most implicit bias research in the USA and highlights the lack of patient-oriented outcome research in this field. Furthermore, it demonstrates that regardless of the effect of implicit bias on patient outcomes, focus on eliminating implicit bias is insufficient to improve the health of people of color. [ABSTRACT FROM AUTHOR]

Technology adoption has been identified as one of the main elements behind the growth of health care expenditures. It has been argued that the health insurance arrangements in the US justify, to a certain extent, the technology-driven rise in costs. Moreover, it eases the adoption of less cost-effective procedures and devices. This paper presents an additional argument by which excessive technology investments may occur: providers of care invest in technology as a way to "signal" their intrinsic (and unobservable) quality. Providers face the option of adopting a new technology. The decision of adoption in itself may convey information about his/her quality: for example, patients conjecture that providers who display newer technology are of higher quality. Providers, being aware of this, may invest in technology to reveal themselves as high quality, Thus, technology adoption could result only from the desire to attract patients. The investment is self-defeating in the sense that if all providers invest, no information about quality is transmitted to patients. We evaluate the argument in a context of demand for health care services where patients have initially no information about the quality of different providers. We show that an incentive to invest as a way to signal quality may or may not lead to overinvestment. It is also possible that only some providers invest. They reveal themselves as high quality providers. The analysis suggests that the argument is more important for some services than for others. Overall, an additional argument for overinvestment in technology in some circumstances is provided. [ABSTRACT FROM AUTHOR]

Summary Background Presentations to emergency departments (EDs) and patient acuity continue to increase. Whilst strategies to deliver safe patient care in the ED are evolving, emergency nurses need to be well educated through specialist qualifications to enable delivery of advanced patient care. This paper presents a comparative analysis of available international practice and competency standards for nurses graduating from emergency nursing courses in Australia, Canada, New Zealand, the United Kingdom, and the United States. Methods CINAHL, Scopus, Ovid MEDLINE, and Embase were searched for papers, published in English, using the terms: ‘emergency’, ‘accident and emergency’, ‘nursing’, ‘competency’, ‘practice standards’, ‘scope of practice’, ‘regulation’, and ‘specialist standards’. Secondary sources from relevant reference lists and professional websites were also searched. Results The standards from the five countries were common across five domains: clinical expertise, communication, teamwork, resources and environment, and legal. None of the standards were specific to the emergency nursing graduate, and there was variability in the level of expertise required for which the standards apply. Conclusions The available practice standards demonstrated some commonality. Consideration of the utility of a universal framework for informing the development of emergency nursing practice standards and emergency nursing curriculum for nurses wishing to specialise is needed. [ABSTRACT FROM AUTHOR]

Background: In 2007, the National Cancer Institute (NCI) launched the NCI Community Cancer Centers Program (NCCCP) as a public-private partnership with community hospitals with a goal of advancing cancer care and research. In order to leverage federal dollars in a time of limited resources, matching funds from each participating hospital were required. The purpose of this paper is to examine hospitals' level of and rationale for co-investment in this partnership, and whether there is an association between hospitals' co-investment and achievement of strategic goals.Methods: Analysis using a comparative case study and micro-cost data was conducted as part of a comprehensive evaluation of the NCCCP pilot to determine the level of co-investment made in support of NCI's goals. In-person or telephone interviews with key informants were conducted at 10 participating hospital and system sites during the first and final years of implementation. Micro-cost data were collected annually from each site from 2007 to 2010. Self-reported data from each awardee are presented on patient volume and physician counts, while secondary data are used to examine the local Medicare market share.Results: The rationale expressed by interviewees for participation in a public-private partnership with NCI included expectations of increased market share, higher patient volumes, and enhanced opportunities for cancer physician recruitment as a result of affiliation with the NCI. On average, hospitals invested resources into the NCCCP at a level exceeding $3 for every $1 of federal funds. Six sites experienced a statistically significant change in their Medicare market share. Cancer patient volume increased by as much as one-third from Year 1 to Year 3 for eight of the sites. Nine sites reported an increase in key cancer physician recruitment.Conclusions: Demonstrated investments in cancer care and research were associated with increases in cancer patient volume and perhaps in recruitment of key cancer physicians, but not in increased Medicare market share. Although the results reflect a small sample of hospitals, findings suggest that hospital executives believe there to be a strategic case for a public-private partnership as demonstrated through the NCCCP, which leveraged federal funds to support mutual goals for advancing cancer care and research. [ABSTRACT FROM AUTHOR]

Hypertension is a prevalent chronic disease that requires ongoing management and self-care. The disease affects 31% of American adults and contributed to or caused the deaths of 348,000 Americans in 2008, fewer than 50% of whom effectively self-managed the disease. However, self-management is complex, with patients requiring ongoing support and easy access to care. Telehealth may help foster the knowledge and skills necessary for those with hypertension to engage in successful self-management. This paper considers the applicability, efficacy, associated risks, and cost-effectiveness of telehealth for individuals and populations with hypertension. Telehealth is a broad term, encompassing telemedicine and mobile health that is used for physician-patient interactions, diagnostics, care delivery, education, information sharing, monitoring, and reminders. Telemedicine may have considerable utility for people diagnosed with hypertension who have poor access or social barriers that constrain access, but potential risks exist. Telehealth technology is evolving rapidly, even in the absence of fully proven cost-effectiveness and efficacy. Considering the cost of inpatient and emergency department care for patients with hypertension, telehealth is a highly attractive alternative, but there are risks to consider. Incorporating telehealth, which is increasingly characterized by mobile health, can increase both the capacity of health care providers and the reach of patient support, clinical management, and self-care. Telehealth studies need improvement; long-term outcome data on cardiovascular events must be obtained, and robust risk analyses and economic studies are needed to prospectively evaluate the safety and cost savings for hypertension self-management. ( Population Health Management 2015;18:192-202) [ABSTRACT FROM AUTHOR]

In the United States, undocumented residents face unique barriers to healthcare access that render them disproportionately dependent on the emergency department (ED) for care. Consequently, ED providers are integral to the health of this vulnerable population. Yet special considerations, both clinical and social, generally fall outside the purview of the emergency medicine curriculum. This paper serves as a primer on caring for undocumented patients in the ED, includes a conceptual framework for immigration as a social determinant of health, reviews unique clinical considerations, and finally suggests a blueprint for immigration-informed emergency care. [ABSTRACT FROM AUTHOR]

Purpose -- The purpose of this article is to alert those in positions of trust and authority that there is an urgent need for improvement throughout the entire health profession credentialing process to fix defects at every stage, from employer responsibilities all the way up to licensing board responsibilities and government oversight. Design/methodology/approach -- This paper takes the form of a narrative review. Findings -- The assumption that layers of safeguards prevent dangerously incompetent or impaired practitioners from continuing to practice in American hospitals is, unfortunately, just that -- an assumption. While the vast majority of healthcare professionals uphold the standards of their professions, a recent public health vulnerabilities report reveals serious defects throughout those safeguard layers and widespread harm that results from actions of relatively few determined miscreants who manage to evade them. This not only undermines public trust, but underscores ways in which governing boards, hospital executives and directors have found themselves liable for failings of their institution's quality assurance provisions. That vulnerability report is the result of investigation into one healthcare worker whose narcotic thefts and drug tampering resulted in thousands of patients exposed, dozens infected with hepatitis C, across several states and multiple missed opportunities to constrain. Originality/value -- Findings of the Maryland state investigation, coupled with other documents, show that long-recognized ethical and legal responsibilities are not being met effectively. [ABSTRACT FROM AUTHOR]

In the US, health care professionals are trained predominantly in uniprofessional settings independent of interprofessional education and collaboration. Yet, these professionals are tasked to work collaboratively as part of an interprofessional team in the practice environment to provide comprehensive care to complex patient populations. Although many advantages of interprofessional education have been cited in the literature, interprofessional education and collaboration present unique barriers that have challenged educators and practitioners for years. In spite of these impediments, one student-led organization has successfully implemented interprofessional education and cross-disciplinary collaboration. The purpose of this paper is to provide a conceptual framework for successful implementation of interprofessional education and collaboration for other student organizations, as well as for faculty and administrators. Each member of the interprofessional team brings discipline-specific expertise, allowing for a diverse team to attend to the multidimensional health needs of individual patients. The interprofessional team must organize around a common goal and work collaboratively to optimize patient outcomes. Successful interdisciplinary endeavors must address issues related to role clarity and skills regarding teamwork, communication, and conflict resolution. This conceptual framework can serve as a guide for student and health care organizations, in addition to academic institutions to produce health care professionals equipped with interdisciplinary teamwork skills to meet the changing health care demands of the 21st century. [ABSTRACT FROM AUTHOR]

Informal care provided to the elderly by their children is proposed as a less expensive alternative to institutional long-term care. This paper explores how the elderly's consumption of medical care changes in response to changes in the informal care they receive from their children. Many earlier studies have ignored both the endogeneity of informal care and the complicated nature of health care utilization data. This paper develops a two-part model with informal care treated as an endogenous regressor and imposes exclusion restrictions on the selection process. The model is fitted using the Bayesian Markov Chain Monte Carlo (MCMC) methods, in particular the Gibbs sampler and the Metropolis-Hasting algorithm. The average treatment effects and the distributions of the treatment effects are obtained via posterior simulation. The results indicate that informal care provides a substitute for nursing home care and hospital inpatient care, but it does not affect paid home health care on average. The treatment effects are heterogeneous. The largest substitution effects occur for nursing home and hospital inpatient care at the intensive margin. The policy analysis suggests that informal care policies targeting the group that incurs the largest substitution effect may help to reduce government spending on Medicaid and Medicare. [ABSTRACT FROM AUTHOR]

. Carruthers BM, van de Sande MI, De Meirleir KL, Klimas NG, Broderick G, Mitchell T, Staines D, Powles ACP, Speight N, Vallings R, Bateman L, Baumgarten-Austrheim B, Bell DS, Carlo-Stella N, Chia J, Darragh A, Jo D, Lewis D, Light AR, Marshall-Gradisbik S, Mena I, Mikovits JA, Murovska M, Pall ML, Stevens S (Independent, Vancouver, BC, Canada; Independent, Calgary, AB, Canada; Department of Physiology and Medicine, Vrije University of Brussels, Himmunitas Foundation, Brussels, Belgium; Department of Medicine,University of Miami Miller School of Medicine and Miami Veterans Affairs Medical Center, Miami, FL, USA; Department of Medicine, University of Alberta, Edmonton, AB, Canada; Honorary Consultant for NHS at Peterborough/Cambridge, Lowestoft, Suffolk, UK; Gold Coast Public Health Unit, Southport, Queensland; Health Sciences and Medicine, Bond University, Robina, Queensland, Australia; Faculty of Health Sciences, McMaster University and St Joseph's Healthcare Hamilton, Hamilton, ON, Canada; Independent, Durham, UK; Howick Health and Medical Centre, Howick, New Zealand; Fatigue Consultation Clinic, Salt Lake Regional Medical Center; Internal Medicine, Family Practice, University of Utah, Salt Lake City, UT, USA; ME/CFS Center, Oslo University Hospital HF, Norway; Department of Paediatrics, State University of New York, Buffalo, NY; Independent, Pavia, Italy; Harbor-UCLA Medical Center, University of California, Los Angeles, CA; EV Med Research, Lomita, CA, USA; University of Limerick, Limerick, Ireland; Pain Clinic, Konyang University Hospital, Daejeon, Korea; Donvale Specialist Medical Centre, Donvale, Victoria, Australia; Departments or Anesthesiology, Neurobiology and Anatomy, University of Utah, Salt Lake City, Utah, USA; Health Sciences and Medicine, Bond University, Robina, Queensland, Australia; Department of Medicina Nuclear, Clinica Las Condes, Santiago, Chile; Whittemore Peterson Institute, University of Nevada, Reno, NV, USA; Miwa Naika Clinic, Toyama, Japan; A. Kirchenstein Institute of Microbiology and Virology, Riga Stradins University, Riga, Latvia; Department of Biochemistry & Basic Medical Sciences, Washington State University, Portland, OR; Department of Sports Sciences, University of the Pacific, Stockton, CA USA). Myalgic encephalomyelitis: International Consensus Criteria (Review). J Intern Med 2011; 270: 327-338. The label 'chronic fatigue syndrome' (CFS) has persisted for many years because of the lack of knowledge of the aetiological agents and the disease process. In view of more recent research and clinical experience that strongly point to widespread inflammation and multisystemic neuropathology, it is more appropriate and correct to use the term 'myalgic encephalomyelitis' (ME) because it indicates an underlying pathophysiology. It is also consistent with the neurological classification of ME in the World Health Organization's International Classification of Diseases (ICD G93.3). Consequently, an International Consensus Panel consisting of clinicians, researchers, teaching faculty and an independent patient advocate was formed with the purpose of developing criteria based on current knowledge. Thirteen countries and a wide range of specialties were represented. Collectively, members have approximately 400 years of both clinical and teaching experience, authored hundreds of peer-reviewed publications, diagnosed or treated approximately 50 000 patients with ME, and several members coauthored previous criteria. The expertise and experience of the panel members as well as PubMed and other medical sources were utilized in a progression of suggestions/drafts/reviews/revisions. The authors, free of any sponsoring organization, achieved 100% consensus through a Delphi-type process. The scope of this paper is limited to criteria of ME and their application. Accordingly, the criteria reflect the complex symptomatology. Operational notes enhance clarity and specificity by providing guidance in the expression and interpretation of symptoms. Clinical and research application guidelines promote optimal recognition of ME by primary physicians and other healthcare providers, improve the consistency of diagnoses in adult and paediatric patients internationally and facilitate clearer identification of patients for research studies. [ABSTRACT FROM AUTHOR]

Clinical research needs to be more useful to patients, clinicians, and other decision makers. To meet this need, more research should focus on patient-centered outcomes, compare viable alternatives, and be responsive to individual patients' preferences, needs, pathobiology, settings, and values. These features, which make comparative effectiveness research (CER) fundamentally patient-centered, challenge researchers to adopt or develop methods that improve the timeliness, relevance, and practical application of clinical studies. In this paper, we describe 10 priority areas that address 3 critical needs for research on patient-centered outcomes (PCOR): (1) developing and testing trustworthy methods to identify and prioritize important questions for research; (2) improving the design, conduct, and analysis of clinical research studies; and (3) linking the process and outcomes of actual practice to priorities for research on patient-centered outcomes. We argue that the National Institutes of Health, through its clinical and translational research program, should accelerate the development and refinement of methods for CER by linking a program of methods research to the broader portfolio of large, prospective clinical and health system studies it supports. Insights generated by this work should be of enormous value to PCORI and to the broad range of organizations that will be funding and implementing CER. Clin Trans Sci 2011; Volume 4: 188-198 [ABSTRACT FROM AUTHOR]

This paper models the predicted impact of tobacco price increases proposed in the United States and Australia during 2009 on smoking prevalence in 2010 while taking account of the effects of financial stress among smokers on cessation rates. Two models of smoking prevalence were developed for each country. In model 1, prevalence rates were determined by price elasticity estimates. In model 2 price elasticity was moderated by financial stress. Each model was used to estimate smoking prevalence in 2010 in Australia and the United States. Proposed price increases resulted in a 1.89% and 7.84% decrease in smoking participation among low socio-economic status (SES) groups in the United States and Australia, respectively. Model 1 overestimated the number of individuals expected to quit in both the United States (0.13% of smokers) and Australia (0.36% of smokers) by failing to take account of the differential effects of the tax on financially stressed smokers. The proportion of low-income smokers under financial stress increased in both countries in 2010 (by 1.06% in the United States and 3.75% in Australia). The inclusion of financial stress when modelling the impact of price on smoking prevalence suggests that the population health returns of increased cigarette price will diminish over time. As it is likely that the proportion of low-income smokers under financial stress will also increase in 2010, future population-based approaches to reducing smoking will need to address this factor. [ABSTRACT FROM AUTHOR]

Despite well-known benefits of health care utilization for the effective management of chronic diseases, the underlying mechanism of understanding health care utilization in ethnic minority population has not been systematically explored. The purpose of this paper is to examine the predictive ability of a health care utilization model by analyzing the interplay between predisposing, enabling, and need factors. The sample consisted of hypertensive Korean American immigrants (KAIs) 40–64 years of age who participated in a self-help intervention for high blood pressure care (SHIP-HBP). Using structured questionnaires, data were collected from 445 KAIs at baseline and analyzed with path analysis. Insurance status and relevant medical history were not just strong direct effects but also carried the most total effect on the health care utilization of these patients. Life priorities, years of residence in the US and perceived income level exerted indirect effects through the participants’ insurance status. Our statistical analysis indicated a good fit for the proposed model ( x2 = 28.4, P = 0.29; NFI = 0.91; CFI = 0.99; RMSEA = 0.02). Overall, the model explained 18% of the variance in health care utilization of hypertensive KAIs. These findings strongly support a need to improve access to health care for KAIs by introducing a variety of community resources and building sustainable community infrastructures. [ABSTRACT FROM AUTHOR]

The United States faces tremendous challenges with its healthcare system. By any standard, it is expensive and performs poorly in most measures of health and thus, is in great need of reform. But how do we reform things without making the situation worse? Some of the more fundamental problems arise from the combination of a fee-for-service payment system for physicians with insurance-based financing care. This combination results in conflicts among the interests of patients, physicians and payers. This paper examines this issue from a decision analytic perspective, starting with a definition of the patient-centered view, and an assessment of the practicality of controlling costs by making healthcare more patient-centric. It then illustrates how fee-for-service models corrupt decision-making and other solutions designed to reign in the abuses of the fee-for-service model and also negatively impacts the quality of decision making for individual patients. Whatever the strategies for health reform, the degree of patient-centeredness of care is a benchmark that allows policy makers to understand how far they have had to deviate from optimal to achieve the desired ends of cost control. [ABSTRACT FROM AUTHOR]

The costs of health care continue to increase rapidly and steeply in the United States. One area of great expense is that of intensive care units (ICUs). The causes of inflation have not been addressed effectively. ICU resources could become stretched such that they may no longer be available. This paper discusses some of the ethics and concerns behind decision making when providing ICU services in the United States. In particular, the use of electronic records with decision making tools, risk-analysis methods, and documentation of patient wishes for extraordinary care may help with better utilization of resources in the future. [ABSTRACT FROM AUTHOR]

This paper will explore how place of residence influences respondents' self-reported health communication difficulties (HCDs) and unmet medical needs (UMNs). Using data from the nationally representative 2003 Community Tracking Study (CTS) Household Survey, the study calculated the proportion of randomly selected respondents from 60 diverse communities, reporting HCDs and UMNs. The percentage of respondents per CTS site reporting HCDs and UMNs varied substantially. Overall, HCDs and UMNs were highly correlated with one another, although several CTS sites were incongruent on these measures. Despite geographic variation, there is a strong correlation between HCDs and UMNs. [ABSTRACT FROM AUTHOR]

BACKGROUND: Tradition has led us to believe that a heavily sedated patient is a comfortable, settled, compliant patient for whom sedation will improve outcome. The current move witnessed in clinical practice today of limiting sedation has led health care in recent years to question the benefit and necessity of routine, continuous sedation for all patients requiring mechanical ventilation. However, as a result there has been a rise in the amount of agitation being reported as being experienced by patients with the daily withdrawal of sedation. AIMS: The purpose of this paper is to review current arguments for and against perserving with agitation versus re-sedating, when it presents during the daily sedation breaks. FINDINGS: Of the literature reviewed, the question to re-sedate the mechanically ventilated agitated patient during sedation breaks remains an issue of contention. Although there is evidence focusing on the psychological effects of long-term sedation and sedation breaks specifically, the complex nature of critical illness in some cases means that individualized care is of paramount importance and in-depth assessment is crucial when deciding to re-sedate in the face of undetermined agitation. Agitation has been closely linked with several incidents that can be detrimental to patient safety, such as removal of lines and unplanned self-extubation. CONCLUSION: The recommendations of this review are that nurses should re-commence sedation if the patient becomes agitated following a sedation break. [ABSTRACT FROM AUTHOR]

In two prior papers, "Properly Documenting a File and Forensic Examination of IME Doctors" and "Qualifications and Paradigms for the Independent Examiner," we first explained how field practitioners can better document case files to withstand challenges, including those made by Independent Examiners (IEs, a.k.a. IMEs, ICE, DME, QME), and addressed forensically examining the IE, as well. The second paper sought to establish reasonable standards and protocols to which IEs should be held. It is thought that, in this way, the examiner's credibility can be established, to say nothing of actuating fair and accurate examinations. Still, despite nationwide protest and outrage among practicing doctors and angry patients, the reality is that in a vast majority of jurisdictions in the U.S., any doctor can become an IE merely by making application with an insurance company or intermediary; for most states, there are simply no standards or guidelines to organize this process. We have always spoken out against this. The previous two papers represent two of the few published works on this subject. This paper will demonstrate the excesses some IEs go to in cutting claims. While we hasten to add that this is not an indictment against all Independent Examiners, these are stories that need to be told because they shed light on what is becoming alarmingly commonplace in health care: IEs who ignore patients, ignore factual medical realities, and ignore sworn testimony, downgrading real injuries under the fiction of being "independent." When called to task, the IE has only to say, "That's my opinion," without threat of lawsuit, discipline, or any form of sanction. We consider such scenarios a moral outrage and an injustice to patients who suffer as the result of biased "independent" examinations. Many IEs do "reviews" and "independent examinations" full time and do not actually treat patients anymore. Although business is booming, it's the patients who lose out. [ABSTRACT FROM AUTHOR]

With the ageing population and therapeutic advances in acute and chronic disease treatment, more patients are living with at least one chronic condition. The management of a patient's chronic condition is complicated by the simultaneous presence of multiple competing comorbidities and the intrapersonal and external factors that influence chronic care. The current US healthcare system is largely organised around the management of acute illness and as a result is struggling to meet the challenges of complex chronic care. These challenges require innovative strategies to improve patient care and clinical outcomes. This paper explores some of the challenges faced by patients, healthcare providers and healthcare systems, and reviews new avenues of health services research that target these challenges. [ABSTRACT FROM AUTHOR]

Background: Outpatient prescription drugs continue to play an ever-increasing role in health care delivery in the United States. This paper focuses on the drugs prescribed by dentists and the patients who receive those drugs. Methods: The authors analyzed data from the 2001 Medical Expenditure Panel Survey (MEPS) for the U.S. community-based population. They developed estimates of the total market for prescription drugs related to a dental visit in terms of total number of prescriptions, total expenditures, and sources of payment. Also included are breakdowns by the type of dentist and the therapeutic class of drug prescribed. They also present a model that identifies the patient characteristics that best predict the likelihood of receiving a dental visit related prescription drug. Results: Dental patients who were 18 years and older, African American patients, patients whose education level was less than a college degree, patients whose dental visit frequency was less than twice a year, and patients without medical insurance were most likely to report a prescription drug. Conclusion: Respondents' socioeconomic background and other demographic factors were related to the likelihood of receiving a prescription drug related to a dental visit. Patient age was related to the therapeutic class of the drug prescribed. Practice Implications: Patients with fewer than two dental visits per year were more likely to report a dental prescription than patients with at least two visits per year. [ABSTRACT FROM AUTHOR]

Competition among hospitals and managed care have forced hospital industry to be more efficient. With higher degrees of hospital competition and managed care penetration, hospitals have argued that the rate of increase in hospital cost is greater than the rate of increase in hospital revenue. By developing a payer-specific case mix index (CMI) for third-party patients, this paper examined the effect of hospital case mix on hospital cost and revenue for third-party patients in California using the hospital financial and utilization data covering 1986–1998. This study found that the coefficients for CMIs in the third-party hospital revenue model were greater than those in the hospital cost model until 1995. Since 1995, however, the coefficients for CMIs in the third-party hospital revenue model have been less than those in hospital cost models. Over time, the differences in coefficients for CMIs in hospital revenue and cost models for third-party patients have become smaller and smaller although those differences are statistically insignificant. [ABSTRACT FROM AUTHOR]

The extent to which the moral hazard caused by health insurance represents economic inefficiency has been the subject of much debate. This paper incorporates health status in a model of moral hazard, and finds that seriously ill patients are likely to exhibit greater moral hazard than healthier patients but the proportion of moral hazard that is inefficient declines with the severity of illness. Because of these competing tendencies, the cost of resource misallocation is parabolic in the severity of illness. The effect of the consumer's initial wealth endowment is also considered. [ABSTRACT FROM AUTHOR]

Blood pressure is not controlled in as many as 50%–75% of hypertensive patients, primarily because of inadequate adherence to treatment. This paper examines the efficacy of a Transtheoretical Model (TTM)–based expert system intervention designed to improve adherence with antihypertensives in a sample of 1227 adults. Participants were proactively recruited and randomly assigned to receive usual care or three individualized expert system reports and a stage-matched manual over 6 months. Participants were surveyed at baseline, and 6, 12, and 18 months. Significantly more of the intervention group participants reported being in Action and Maintenance at follow-up time points (ie, 73.1% of the treatment group versus 57.6% of the control group at 12 months and 69.1% of the treatment group versus 59.2% of the control group at 18 months). Scores on a behavioral measure of nonadherence differed significantly at follow-up time points. TTM-based expert system interventions have the potential for a significant impact on entire populations of individuals who fail to adhere, regardless of their readiness to change. [ABSTRACT FROM AUTHOR]

Hepatitis C virus (HCV) is the most prevalent blood-borne infectious disease in the United States, especially among drug users, and coinfection with HIV is common. Because drug users are often medically underserved, drag treatment units are important sites of opportunity for providing services for these infectious diseases. Given the commonalities in the routes of transmission of HIV and HCV, and the fact that many drug treatment units have established an infrastructure to provide HIV services, some have suggested integrating HCV services into those already established for HIV. Using data collected in a telephone survey with 89 drug treatment units throughout the United States, this paper examines the extent to which drug treatment units have expanded their HIV services to include those for HCV, and the extent to which this expansion was facilitated by having HIV services in place. Overall, a greater proportion of methadone maintenance than drug-free treatment units provided services for HIV and HCV. The majority of units in both modalities that provided HIV- and HCV-related services expanded their HIV service delivery to include similar HCV services, and one third expanded all of their HIV services. A large number of these units, however, indicated that having an HIV service infrastructure did not facilitate this expansion, often because the units wanted to emphasize differences in the two viral infections. Policy makers and individual treatment units need to develop strategies that capitalize on existing infrastructures while maintaining the distinction between HIV and HCV primary and secondary prevention efforts. [ABSTRACT FROM AUTHOR]

With the advent of Medicaid Managed Care, health care professionals and administrators have sought ways to increase patient compliance and appropriate utilization of services under a capitated system. The major focus has been on medical managed care and utilization review to control cost. This paper focuses on the development and standardization of social indicators to identify the biopsychosocial problems that cause medical noncompliance and inappropriate utilization of medical services by the Medicaid patient. The development of what is called Life Indicators is discussed and serves as a basis for enhancing the medical case management model to control cost when providing services to patients with complex medical and social problems. [ABSTRACT FROM AUTHOR]

Italian and American hospitals, in two different periods, have been urged by external circumstances to extensively redesign their quality improvement strategies. This paper, through the use of a survey administered to chief quality officers in both countries, aims to identify commonalities and differences between the two systems and to understand which approaches are effective in improving quality of care. In both countries chief quality officers report quality improvement has become a strategic priority, clinical governance approaches, and tools—such as disease-specific quality improvement projects and clinical pathways—are commonly used, and there is widespread awareness that clinical decision making must be supported by protocols and guidelines. Furthermore, the study clearly outlines the critical importance of adopting a system-wide approach to quality improvement. To this extent Italy seems lagging behind compared to US in fact: (i) responsibilities for different dimensions of quality are spread across different organizational units; (ii) quality improvement strategies do not typically involve administrative staff; and (iii) quality performance measures are not disseminated widely within the organization but are reported primarily to top management. On the other hand, in Italy chief quality officers perceive that the typical hospital organizational structure, which is based on clinical directories, allows better coordination between clinical specialties than in the United States. In both countries, the results of the study show that it is not the single methodology/model that makes the difference but how the different quality improvement strategies and tools interact to each other and how they are coherently embedded with the overall organizational strategy. [ABSTRACT FROM AUTHOR]

Abstract In 1965, Glaser and Strauss (1965) offered the concept of "awareness contexts" to explain what patients in hospitals do or don't know about their death trajectories. Awareness ranges from closed (where patients are completely unaware and family and providers protect "the secret") to open (where all parties communicate openly and honestly). While closed awareness was the norm in 1960s, open awareness is now considered standard practice in US, a reflection of mounting evidence that patients, families, and providers benefit from clear and honest communication at end of life (Seale et al., 1997; Wright et al., 2008). Despite the known benefits of open awareness, many terminal patients remain unaware or confused about their prognoses (Chen et al., 2017). This paper asks why, in an era of open awareness, are patients and families uncertain about dying? To answer this question, we focus on an aspect of Glaser and Strauss's theory that remains relatively understudied by researchers, namely the role of institutional and organizational realities in shaping awareness contexts. Based on interviews with 43 family members of deceased patients who died at General Hospital in the Midwestern US, we argue that two related conditions in hospitals—the increased specialization of medical professionals and the fragmentation of patient care—serve as important context for the death awareness of patients and families. Highlights • Specialized and fragmented health care impacts end of life experiences for patients and families. • Patients and families experiencing specialized and fragmented care experience uncertain prognoses. • Uncertain prognoses at end of life can leave families unprepared for death and/or grief stricken. [ABSTRACT FROM AUTHOR]

Abstract Our paper explores how legal status stratification shapes the health and health care of low-income patients with chronic illnesses in the U.S. healthcare safety net. Drawing on data from over two years of ethnographic fieldwork at urban safety-net clinics, we examine efforts by Complex Care Management (CCM) teams to stabilize patients with uncontrolled chronic illnesses through primary care-integrated support. We show that stratified citizenship and geographic variability correspond to different possibilities for health care. We suggest an approach to immigration as a structural determinant of health that accounts for the complex, stratified, and changing nature of citizenship status. We also highlight how geographical differences and interactions among local, state, and federal policies support the notion that citizenship is stratified across multiple tiers with distinctive possibilities and constraints for health. While county-based health plans at each of the study sites include residents with varying legal status, lack of formal legal status remains a substantial obstacle to care. Many immigrants are unable to take full advantage of primary and specialty care, resulting in unnecessary morbidity and mortality. In some cases, patients have returned to their country of origin to die. While CCM teams provide an impressive level of support to assist immigrant patients in navigating healthcare and immigration bureaucracies, legal and geographic stratification limit their ability to address broader aspects of these patients' social context. Highlights • Immigration status shapes the health of chronically ill U.S. safety net patients. • Local, state, and federal policies differentially stratify legal status and health. • Ethnography illustrates health impacts of stratified legal status. • Complex care management patients lacking legal status face obstacles to care. • Legal and geographic stratification impede immigrant CCM patients' health. [ABSTRACT FROM AUTHOR]

As some preventive medicine physicians have been denied medical licenses for not engaging in direct patient care, this paper attempts to answer the question, "Do preventive medicine physicians practice medicine?" by exploring the requirements of licensure, the definition of "practice" in the context of modern medicine, and by comparing the specialty of preventive medicine to other specialties which should invite similar scrutiny. The authors could find no explicit licensure requirement for either a certain amount of time in patient care or a number of patients seen. No physicians board certified in Public Health and General Preventive Medicine sit on any state medical boards. The authors propose that state medical boards accept a broad standard of medical practice, which includes the practice of preventive medicine specialists, for licensing purposes. [ABSTRACT FROM AUTHOR]

Shared decision making is a process in which patients are involved as active partners with the clinician in clarifying acceptable medical options and in choosing a preferred course of clinical care. Shared decision making offers a way of individualizing recommendations, according to patients'' special needs and preferences, when some patients may benefit from an intervention but others may not. This paper clarifies how the U.S. Preventive Services Task Force (USPSTF) envisions the application of shared decision making in the execution of screening and chemoprevention. Unlike conventional USPSTF reports, this paper is neither a systematic review nor a formal recommendation. Instead, it is a concept paper that includes a commentary on the current thinking and evidence regarding shared decision making.Although the USPSTF does not endorse a specific style of decision making, it does encourage informed and joint decisions. This means that patients should be informed about preventive services before they are performed, and that the patient–clinician partnership is central to decision making. The USPSTF suggests that clinicians inform patients about preventive services for which there is clear evidence of net benefit, and, if time permits, about other services with high visibility or special individual importance. Clinicians should make sure that balanced, evidence-based information about the service (including the potential benefits and harms, alternatives, and uncertainties) is available to the patient if needed. For preventive services for which the balance of potential benefits and harms is a close call, or for which the evidence is insufficient to guide a decision for or against screening, clinicians should additionally assist patients in determining whether individual characteristics and personal preferences favor performing or not performing the preventive service.The USPSTF believes that clinicians generally have no obligation to initiate discussion about services that have either no benefit or net harm. Nonetheless, clinicians should be prepared to explain why these services are discouraged and should consider a proactive discussion for services with high visibility or special individual importance or for services for which new evidence has prompted withdrawal of previous recommendations. [Copyright &y& Elsevier]

Abstract: This paper concerns care of refugees from Southeast Asia who speak little English and are relatively unfamiliar with the formal health care system in the United States. It aims to demystify the behaviors of refugee patients and to support health practitioners who are attempting to care for them. Western medicine is discussed in terms of the expectations that refugees tend to hold of it, and of the conflicts with Southeast Asian beliefs and practices which it presents. Despite language differences, health care agents can increase the effectiveness of their communication with persons from Southeast Asia, primarily by allowing for their viewpoints. Topics discussed are: the first encounter with a refugee patient: use of interpreters; obtaining informed consent: "the passive obedient" patient: the "non-compliant" patient: body image: sources of social support for healing; use of medications; traditional self-care practices; and death and depression. (Am J Public Health 1983: 73:431-438.) [ABSTRACT FROM AUTHOR]

This paper discusses problems encountered by health workers and ghetto-minority patients in their relations with each other and how they may be handled. The problems are seen in a practical way. [ABSTRACT FROM AUTHOR]

Increasing “patient engagement” has become a priority for health care organizations and policy-makers seeking to reduce cost and improve the quality of care. While concepts of patient engagement have proliferated rapidly across health care settings, little is known about how health care providers make use of these concepts in clinical practice. This paper uses 20 months of ethnographic and interview research carried out from 2015 to 2016 to explore how health care providers working at two public, urban, safety-net hospitals in the United States define, discuss, and assess patient engagement. We investigate how health care providers describe engagement for high cost patients—the “super-utilizers” of the health care system—who often face complex challenges related to socioeconomic marginalization including poverty, housing insecurity, exposure to violence and trauma, cognitive and mental health issues, and substance use. The health care providers in our study faced institutional pressure to assess patient engagement and to direct care towards engaged patients. However, providers considered such assessments to be highly challenging and oftentimes inaccurate, particularly because they understood low patient engagement to be the result of difficult socioeconomic conditions. Providers tried to navigate the demand to assess patient engagement in care by looking for explicit positive and negative indicators of engagement, while also being sensitive to more subtle and intuitive signs of engagement for marginalized patients. [ABSTRACT FROM AUTHOR]