Emergency department (ED) crowding has become a major barrier to receiving timely emergency care in the United States. Despite widespread recognition of the problem, the research and policy agendas needed to understan...
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Emergency department (ED) crowding has become a major barrier to receiving timely emergency care in the United States. Despite widespread recognition of the problem, the research and policy agendas needed to understand and address ED crowding are just beginning to unfold. We present a conceptual model of ED crowding to help researchers, administrators, and policymakers understand its causes and develop potential solutions. The conceptual model partitions ED crowding into 3 interdependent components: input, throughput, and output. These components exist within an acute care system that is characterized by the delivery of unscheduled care. The goal of the conceptual model is to provide a practical framework on which an organized research, policy, and operations management agenda can be based to alleviate ED crowding.
Background: The '2 week wait' directive (Health Service Circular (HSC 1998/242) guaranteeing that 'everyone with suspected breast cancer will be able to see a specialist within two weeks of their general p...
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Background: The '2 week wait' directive (Health Service Circular (HSC 1998/242) guaranteeing that 'everyone with suspected breast cancer will be able to see a specialist within two weeks of their general practitioner (GP) deciding they need to be seen urgently' is a unique audited approach to access for the British National Health Service, the effects of which have been assessed in a non-academic symptomatic breast clinic. Methods: New GP referrals (n = 607) were reviewed prospectively in two comparable 3-month intervals, beginning 1 April 1998 and 1 April 1999, to determine the probability of a breast cancer diagnosis from the referral letter and the effects of the directive on waiting times for appointments and utilization of clinics. Results: The urgency of referral was not specified in 53 per cent of GP referrals. For the 'urgent' cases (25 per cent of all new referrals) the probability of a final diagnosis of breast cancer was 0.19. The breast specialists prospectively achieved a rate of 0.26 from 99 per cent of the same referral letters. 'Urgent' referrals did not wait significantly longer in 1999 (median 9 versus 10 days) but waiting times for new appointments overall increased (13 versus 16 days;P < 0.01), and this was greatest for 'routine' referrals (14 versus 21 days;P < 0.001). These changes were caused by an increase in the number of clinic appointments, due to significant increases in median number of visits to diagnosis or discharge and clinic non-attendance in 1999, resulting in overbooking. Telephonic communications were associated with faster median access times (fax 8 days;telephone 2 days), relative to mailed referrals (19 days) (P < 0.01). Conclusion: Breast specialists were better overall at assessing the probability of a breast cancer diagnosis. The waiting time for 'urgent' appointments was unchanged following HSC 1998/242, but there was an increased wait for other patients, especially those assessed as having a lower probability of cancer.
Home telecare is a promising method of improving access to care for rural and urban populations. It requires, however, that patients accept the installation and use of equipment in their home. How patients perceive ho...
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Home telecare is a promising method of improving access to care for rural and urban populations. It requires, however, that patients accept the installation and use of equipment in their home. How patients perceive home telecare may influence its acceptability and diffusion. We developed a questionnaire to assess patients' impressions of the risks and benefits of home telecare. A preliminary 20-item questionnaire was developed and tested on 32 subjects. It proved to be of acceptable reliability (Cronbach's alpha of 0.8) and validity, but three items appeared to be redundant. The final 17-item version was tested twice on 10 more subjects and was found to have high test-retest reliability. Most subjects showed an overall positive attitude towards home telecare and agreed it could improve their health. Many were concerned about being able to trust the equipment. The questionnaire can be used to investigate the acceptance of telemedicine and to improve the design of applications.
The end of centuries, and especially millennia, have always been a time for soothsayers. Such times offer rich pickings, especially for the prophets of doom! The last 50 years have seen a meteoric development in the s...
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The end of centuries, and especially millennia, have always been a time for soothsayers. Such times offer rich pickings, especially for the prophets of doom! The last 50 years have seen a meteoric development in the specialty of Plastic Surgery. However, as the end of the century and millennium approaches, the voice of disquiet can be increasingly heard amongst Plastic Surgeons, The cause of this anxiety is the increasing number of Plastic Surgery techniques that are being performed by non Plastic Surgeons, Some even speak of the demise of Plastic Surgery as a specialty, or at least its marginalisation to cosmetic surgery. Has the specialty of Plastic Surgery really been a star which has burned too brightly? Is it really in danger of burning out? My central thesis is that the specialty of Plastic Surgery is unique and has an important contribution to make into the future. Plastic Surgery differs around the world such that some of what I say is specific to conditions in Britain. I will start by considering what is meant by the term 'Plastic Surgery'. After a brief look at the past I will review the likely future changes in the techniques of Plastic Surgery. Then I will move on to explore the future of the specialty and the factors that will determine its future. Finally I will offer some immediate priorities.
Objective To describe the variety of arrangements for providing out-of-hours dental care in the UK. Design A telephone interview survey of health authorities and health boards. Setting United Kingdom. Subjects 104 hea...
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Objective To describe the variety of arrangements for providing out-of-hours dental care in the UK. Design A telephone interview survey of health authorities and health boards. Setting United Kingdom. Subjects 104 health authority contacts, usually consultants in dental public health, dental advisers or others in a position to describe the local dental service arrangements. Results At weekends, 25 authorities have no formal dental care arrangements for unregistered patients, 55 have separate arrangements for registered and unregistered patients, and 44 have 'universal access' arrangements - for anyone in an area, regardless of their registration status. On weekday nights over two-thirds (82/124) of UK health authorities have no formal arrangements for unregistered patients. Where there are separate 'safety-net' services intended for unregistered patients only they are usually (in 48 of 55 authorities) emergency treatment sessions. A fifth of authorities reported planned changes to their local out-of-hours arrangements, including the introduction of telephone triage, and moves to make care available at more times, to more people or from centralised premises. Conclusions There is extremely wide geographical variation in the organisation of out-of-hours dental services provided in the United Kingdom. In many parts of the UK there are no formal out-of-hours care arrangements for unregistered patients, even at weekends. This unequal provision will mean inequitable access for many unregistered patients. With increasing demands from a growing unregistered population, and various government initiatives to make primary care services more integrated and accessible, the highly fragmented pattern of provision in many areas may no longer be acceptable.
We explored the feasibility of realtime telemedicine in Croatia using Internet videoconferencing. A 33 kbit/s link was established between a team of specialists in the General Hospital 'Sveti Duh' in Zagreb an...
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We explored the feasibility of realtime telemedicine in Croatia using Internet videoconferencing. A 33 kbit/s link was established between a team of specialists in the General Hospital 'Sveti Duh' in Zagreb and a general practitioner's clinic in Selca, on the island of Brac. During a two-week study, 16 patients (median age 51 years) were studied. Twenty-one teleconsultations (seven initial and 14 follow-up visits) were conducted, 13 with a specialist in internal medicine, six with a surgeon and two with a neurologist. In 18 cases (86%) telemedicine successfully replaced hands-on examination. The mean duration of the teleconsultations was 7.2 min (initial visits 7.4 min, follow-up visits 7.1 min). Each computer system cost about US$700. The total connection cost for the study was US$4.95. The teleconsultations saved the patients US$272 in travel costs. We suggest forming a permanent on-line specialist service connected to networked clinics via the Internet to improve access to health-care in Croatia.
Comments on the April 2000 publication of National Service Frameworks (NSF) for coronary heart disease (CHD), as part of the modernization program of Great Britain's National Health Service. Commendation of the NS...
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Comments on the April 2000 publication of National Service Frameworks (NSF) for coronary heart disease (CHD), as part of the modernization program of Great Britain's National Health Service. Commendation of the NSF authors for recognizing that palliative care may benefit CHD patients; Value of the NSF in CHD for patients; Challenges involved in palliative care for CHD.
When primary health care (PHC) was developed and implemented in developing countries, oral health was not included. The present consequences are marked disparities in the distribution of oral health care, since conven...
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When primary health care (PHC) was developed and implemented in developing countries, oral health was not included. The present consequences are marked disparities in the distribution of oral health care, since conventional dentistry can only serve relatively few people and at high costs. Oral health care is virtually non-existent in rural areas of most developing countries where more than 80 per cent of the population live. More recently, community based oral health programmes have been initiated in some countries to fill the gap. These programmes give more emphasis on oral health promotion and on the prevention of oral diseases than on treatment of its consequences, since history has shown that the latter is ineffective in preventing oral diseases. Unfortunately, most of these oral health programmes have been implemented next to the existing PHC system and hence they face enormous management, logistic and financial problems, which seriously threaten their sustainability. This paper presents a proposal to counteract the problems that many countries face in developing an adequate primary oral health care (POHC) service.
This article presents findings from a participatory action research project in a municipality in southern Brazil that models a new and holistic approach to broadening women's contraceptive choices. The project enc...
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This article presents findings from a participatory action research project in a municipality in southern Brazil that models a new and holistic approach to broadening women's contraceptive choices. The project encourages a collaborative process between researchers, community members, and public health managers to diagnose service-delivery problems, to design and implement interventions, and to evaluate their effectiveness. Findings from the baseline evaluation revealed major constraints in availability of and access to family planning and reproductive health services for women, as well as severe deficiencies in quality of care. Interventions designed to address these weaknesses, bound by the limited resources of the public sector, focused on training, restructuring of providers' roles and service-delivery patterns, the management process, the creation of a referral center, and the introduction of injectables, vasectomy services, and a program for adolescents. Evaluation results show the project's considerable impact in broadening reproductive options, although not all issues, especially those related to sustainability, have been resolved.
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