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This ethnographic study of 'goal displacement' in an adult day care center explains how and why certain goals come to surpass others in the organizational practices of elder day care settings. Adult day care is often oriented towards providing family caregivers with respite rather than attempting to directly improve the lives of the elders themselves. Although the adult day care center studied (CADC) was ostensibly founded to care for and improve the lives of elders with dementia, the center instead focused on providing respite for family caregivers who depended on the center for relief from care-giving. I show how the goals that CADC could realistically pursue, and the population it ultimately came to serve, were limited by the larger structural setting in which the organization operated. CADC's dependence on a limited pool of external resources of questionable quality converged with the organizational demands of a difficult population in such a way that simply providing a safe and orderly environment strained the organization to the limit. Providing care that aimed to directly improve elders' lives was seen as unreasonable, because this would have required unavailable resources, personnel, and training. In contrast, helping family caregivers by adopting a 'respite focus' was seen as reasonable and worthwhile. Thus, family caregivers came to supplant elders as the de facto clients of CADC. The goal of improving elders' lives remained, but only in brochures and ideology, not organizational practice. Still, this goal remained an important part of the organizational discourse of CADC, since widely shared cultural understandings of the type of care elders deserve, constrained the way the organization could present itself.

Since devolution, the four countries of the United Kingdom have pursued strikingly different National Health Service (NHS) reforms. While England created a supply-side market more radical than the previous internal market system, Wales moved to a softer version of the purchaser/provider split emphasizing localism. This article deploys institutional theory to analyze the forces shaping change, and describes the hybrid forms of economic organization emerging, including the economic regulation model implemented in England. The schism that has resulted in separate NHS subsystems warrants a different analysis from the more familiar phenomenon of infield divergence. We argue that schism was triggered by political-regulatory influences rather than economic or other social institutional forces, and predict that other decentralized public healthcare systems may follow a similar path. While political-regulatory, normative, and cognitive institutional influences push in the same direction in Wales, the misalignment of political-regulatory and normative elements in England looks set to result in a period of organizational turbulence.

This study examined predictors of readmission for a sample of 522 adolescents enrolled in Medicaid and admitted to three inpatient psychiatric hospitals in Maryland. Comprehensive data on clinical, treatment, and health care system characteristics were collected from archival sources (medical records, Medicaid claims, and the Area Resource File). Predictors of readmission were examined with bivariate (Kaplan Meier) and multivariate (Cox Regression) survival techniques. One-year readmission rates were 38% with the majority occurring within 3 months after discharge. Adolescent demographic (age and gender), clinical (severity of symptoms, comorbidity, suicidality) and family characteristics (level of family risk) were associated with readmission. However, treatment factors including type of aftercare, postdischarge living environment, medication noncompliance, and hospital provider were among the strongest predictors of readmission. Study findings underscore the importance of careful discharge planning and linkage to appropriate aftercare. The differing rates of readmission across hospitals also suggest that organizational level factors may play a vital role in determining treatment outcomes. Keywords: inpatient psychiatric hospitalization, adolescents, readmission

Background. Multidimensional preventive home visit programs aim at maintaining health and autonomy of older adults and preventing disability and subsequent nursing home admission, but results of randomized controlled trials (RCTs) have been inconsistent. Our objective was to systematically review RCTs examining the effect of home visit programs on mortality, nursing home admissions, and functional status decline. Methods. Data sources were MEDLINE, EMBASE, Cochrane CENTRAL database, and references. Studies were reviewed to identify RCTs that compared outcome data of older participants in preventive home visit programs with control group outcome data. Publications reporting 21 trials were included. Data on study population, intervention characteristics, outcomes, and trial quality were double-extracted. We conducted random effects meta-analyses. Results. Pooled effects estimates revealed statistically nonsignificant favorable, and heterogeneous effects on mortality (odds ratio [OR] 0.92, 95% confidence interval [CI], 0.80-1.05), functional status decline (OR 0.89, 95% CI, 0.77- 1.03), and nursing home admission (OR 0.86, 95% CI, 0.68-1.10). A beneficial effect on mortality was seen in younger study populations (OR (I.74, 95% CI, 0.58-0.94) but not in older populations (OR 1.14, 95% CI, 0.90-1.43). Functional decline was reduced in programs including a clinical examination in the initial assessment (OR 0.64, 95% CI, 0.48-0.87) but not in other trials (OR 1.00, 95% CI, 0.88-1.14). There was no single factor explaining the heterogenous effects of trials on nursing home admissions. Conclusion. Multidimensional preventive home visits have the potential to reduce disability burden among older adults when based on multidimensional assessment with clinical examination. Effects on nursing home admissions are heterogeneous and likely depend on multiple factors including population factors, program characteristics, and health care setting. Key Words: Aged--Geriatric assessment--Home visit--In-home--Multidimensional geriatric assessment--Older adults--Preventive home visit.

Background. The quality of health care for older Americans with multiple chronic conditions is suboptimal. We designed 'Guided Care' (GC) to enhance quality of care by integrating a registered nurse, intensively trained in chronic care, into primary care practices to work with physicians in providing comprehensive chronic care to 50-60 multimorbid older patients. Methods. We hypothesized that GC would improve the quality of health care for this population. In 2006, we began a cluster-randomized controlled trial of GC at eight practices (n = 49 physicians). Older patients of these practices were eligible to participate if they were at risk for using health services heavily during the coming year. Teams of two to five physicians and their at-risk older patients were randomized to either GC or usual care (UC). Six months after baseline, participants rated the quality of their health care by answering validated closed-ended questions from telephone interviewers who were masked to group assignment. Results. Of the 13,534 older patients screened, 2391 (17.7%) were eligible to participate in the study, of which 904 (37.8%) gave informed consent and were cluster-randomized. After 6 months, 93.8% and 93.2% of the GC and UC participants who remained alive and eligible completed telephone interviews. GC participants were more likely than UC participants to rate their care highly (adjusted odds ratio = 2.0, 95% confidence interval, 1.2-3.4, p = .006), and primary care physicians were more likely to be satisfied with their interactions with chronically ill older patients and their families (p < .05). Conclusions. GC improves important aspects of the quality of health care for multimorbid older persons. Additional data will become available as this trial continues. Key Words: Multimorbid--Care management--Randomized trial--Self-management--Quality of care.

The systematic adoption of 'second-generation' comprehensive geriatric assessment instruments, initiated with the Minimum Data Set (MDS) implementation in U.S. nursing homes, and continued with the uptake of related MDS instruments internationally, has contributed to the creation of large patient-level data sets. In the present special article, we illustrate the potential of analyses using the MDS data to: (a) identify novel prognostic factors; (b) explore outcomes of interventions in relatively unselected clinical populations; (c) monitor quality of care; and (d) conduct comparisons of case mix, outcomes, and quality of care. To illustrate these applications, we use a sample of elderly patients admitted to home care in 11 European Home Health Agencies that participated in the AgeD in Home Care (AD-HOC) project, sponsored by the European Union. The participants were assessed by trained staff using the MDS for Home Care, 2.0 version. We argue that the harmonization by InterRAI of the MDS forms for different health settings, referred to as 'the third generation of assessment,' has produced the first scientific, standardized methodology in the approach to effective geriatric care. Key Words: Comprehensive geriatric assessment--Minimum data set--Scales--Older adults--Nursing homes--Resident assessment instrument--Home care.

Background. The effectiveness of community-based geriatric intervention models for vulnerable older adults is controversial. We evaluated a problem-based multidisciplinary intervention targeting vulnerable older adults at home that promised efficacy through better timing and increased commitment of patients and primary care physicians. This study compared the effects of this new model to usual care. Methods. Primary care physicians referred older people for problems with cognition, nutrition, behavior, mood, or mobility. One hundred fifty-one participants (mean age 82.2 years, 74.8% women) were included in a pseudocluster randomized trial with 6-month follow-up for the primary outcomes. Eighty-five participants received the new intervention, and 66 usual care. In the intervention arm, geriatric nurses visited patients at home for geriatric assessment and management in cooperation with primary care physicians and geriatricians. Modified intention-to-treat analyses focused on differences between treatment arms in functional abilities (Groningen Activity Restriction Scale-3) and mental well- being (subscale mental health Medical Outcomes Study [MOS]-20), using a mixed linear model. Results. After 3 months, treatment arms showed significant differences in favor of the new intervention. Functional abilities improved 2.2 points (95% confidence interval [CI], 0.3-4.2) and well-being 5.8 points (95% CI, 0.1-11.4). After 6 months, the favorable effect increased for well-being (9.1; 95% C1, 2.4-15.9), but the effect on functional abilities was no longer significant (1.6; 95% CI, 0.7 to 3.9). Conclusions. This problem-based geriatric intervention improved functional abilities and mental well-being of vulnerable older people. Problem-based interventions can increase the effectiveness of primary care for this population. Key Words: Primary health care--Frailty--Health services research--Multidimensional geriatric assessment--Health services for the aged.

The study compares the effects of structural bases and functional elements of social support on mental health in Taiwan and the United States, using the study conducted in the United States by Lin, Ye, and Ensel (1999) as a reference. Based on a nationally representative sample of Taiwanese adults (n = 2,835), a fundamental similarity in social support structure and function between the two countries was observed. First, the structural bases of social support had a hierarchical order in their effects on depression: Binding (presence of an intimate relationship) was the strongest in reducing depression, whereas belonging (community participation) was the weakest, with bonding (social networks) in between. Regarding the functional elements, perceived social support was a better protector of mental health than actual social support, a finding in line with previous research. On the other hand, several notable differences in the structural bases and functional elements of social support between the two societies were observed, possibly due to the differential cultural and historical characteristics.

The Multisite Opiate Substitution Treatment study evaluated whether adhering to clinical-trial-derived practice guidelines improves treatment outcomes of unselected opiate-dependent patients seen in everyday practice. Clinics that were relatively concordant (n = 4) or nonconcordant (n = 4) with guidelines concerning medication dose levels and psychosocial service provision were identified. Staff interviewed 256 patients at intake and 6-month follow-up regarding past month heroin use, criminal activities, and mental health. To represent real-world practice conditions, clinics provided care in accordance with their usual approach, and no patient exclusion criteria were employed. Patients in each type of clinic were similar at baseline, but by follow-up, heroin use and mental health outcomes were significantly better in guideline-concordant clinics than in guideline-discordant clinics. Notably, 60.6% of patients in concordant clinics had urinalysis-confirmed heroin abstinence versus only 40.0% in nonconcordant clinics. Following research-derived practice guidelines seems to increase opiate substitution treatment effectiveness for opiate-dependent patients in the real world. Keywords: Opioid substitution; Evidence-based medicine; Clinical practice guidelines; Heroin dependence; Effectiveness research

Purpose: This article reports on a study to identify 'building blocks' for quality report cards for geriatric care. Its aim is to present (a) the results of the study and (b) the innovative step-by-step approach that was developed to arrive at these results. Design and Methods: We used Concept Mapping/Structured Conceptualization to define the building blocks. Applied to this study, we carried out Concept Mapping using several data collection methods: (a) a Web search, (b) semistructured interviews, (c) document analysis, (d) questionnaires, and (e)focus groups. Results: The findings showed that, although home care and institutional care for elderly adults share many quality themes, experts need to develop separate quality report cards for the two types of geriatric care. Home care consumers attach more value to the availability, continuity, and reliability of care, whereas consumers of institutional care value privacy, respect, and autonomy most. This study also showed, unlike many other quality report card studies, that consumers want information on structure, process and outcome indicators, and rating outcome indicators such as effectiveness and safety of care both for home care and for institutional care. Concept Mapping proved to be a valuable method for developing quality report cards in health care. Implications: Building blocks were delivered for two quality report cards for geriatric care and will be used when quality report cards are built in The Netherlands. For the U.S. context, this study shows that current national report cards for geriatric care should be supplemented with quality-of-life data. Key Words: Indicators, Quality information, Choice, Performance, Health care consumers, Regulated competition

Health care professionals' and trainees' conceptions of their responsibilities to patients can change over time for a number of reasons: evolving career goals, desires to serve different patient populations, and changing family obligations, for example. Some changes in conceptions of responsibility are healthy, but others express moral damage. Clinicians' changes in their conceptions of what they are responsible for express moral damage when their responses to others express a meager, rather than robust, sense of what they owe others. At least two important expressions of moral damage in the context of health care are these., callousness and divestiture. Callousness describes the poor condition of a clinician's capacity for moral perception; when her capacity to accurately appreciate features of moral relevance that configure others' needs, vulnerabilities, and desert of care diminishes, such that she fails to respond with care to those for whom she has duties to care, she is callous. Callousness has been explored in detail elsewhere, (1) and so the focus of this paper is divestiture. A clinician divests when the value of responding with care to others becomes less centrally and importantly constitutive of his personal and professional identity. Divestiture has important consequences for patients and health professions education, which I will explore here. Keywords: callousness, clinical moral perception, legalism, moral damage, professionlism

The degree of substance-induced syndrome (SIS) was evaluated in 5,116 acutely hospitalized suicidal psychiatric inpatients. Admission and discharge severity ratings were made by academic attendings using structured forms. Outcome variables analyzed include ratings of psychiatric symptom severity on admission and discharge, length of stay, severity of SIS, and severity of alcohol/drug problems. Suicidal inpatients rated with a high degree of SIS were more likely to be homeless, to be unemployed, to be uncooperative, to have shorter lengths of stay, and to show a more rapid improvement in symptoms. These patients represent a subgroup of the co-occurring disorders population having a high degree of addiction severity with temporary substance-induced suicidal syndromes and are subjected to the most expensive level of care in the mental health system. Implications of these findings include the fact that psychiatric inpatient services need to provide intensive addiction intervention treatment and that outpatient addiction services need improved capability and capacity to care for suicidal patients. Keywords: Suicide; Substance induced; Alcohol; Drug

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.apergo.2005.07.003 Byline: Ben-Tzion Karsh (a), Kamisha Hamilton Escoto (b), John W. Beasley (c), Richard J. Holden (b) Keywords: Patient safety; Medical error; Reporting systems Abstract: The release of the Institute of Medicine () report 'To Err is Human', brought attention to the problem of medical errors, which led to a concerted effort to study and design medical error reporting systems for the purpose of capturing and analyzing error data so that safety interventions could be designed. However, to make real gains in the efficacy of medical error or event reporting systems, it is necessary to begin developing a theory of reporting systems adoption and use and to understand how existing theories may play a role in explaining adoption and use. This paper presents the results of a 9-month study exploring the barriers and facilitators for the design of a statewide medical error reporting system and discusses how several existing theories of technology acceptance, adoption and implementation fit with many of the results. In addition we present an integrated theoretical model of medical error reporting system design and implementation. Author Affiliation: (a) Department of Industrial Engineering, University of Wisconsin-Madison, 1513 University Avenue, Room 387, Madison, WI 53706, USA (b) Department of Industrial Engineering, University of Wisconsin-Madison, 1513 University Avenue, Room 392, Madison, WI 53706, USA (c) Department of Family Medicine, University of Wisconsin-Madison, 777 South Mills Street, Room 2812, Madison, WI 53715, USA Article History: Received 22 February 2005; Accepted 15 July 2005

In the context of demographic transition, one would expect public health planners to allocate resources according to changing needs. This paper explores the effects that definitions of population ageing have on the images of, and subsequent responses to, demographic transition in the United States. Data are drawn from the 1988 U.S. Census and from a 20-per cent national random sample of Medicare patients during the same period (n = 1.9 million). Main findings are that supply and use of acute services do differ according to definitions and the way in which population ageing has occurred; that, regardless of definition, older people in high-ageing states make far greater use of posthospital home health care than in low-ageing states; and that, although individual-level clinical factors appear central to rehabilitative decisions, all states seem to use very old age (85-plus) as a proxy to determine who goes where, with low-ageing states also affected by structural constraints at the hospital and market levels. KEY WORDS - Demography, health services planning, Medicare, stroke, social burden of ageing.

In recent years considerable attention has been given to the effects of universal, first-dollar coverage for health care services as provided under Canada's health care system. However, no consideration has been given to the stability of these effects through periods of changing economic climate. In this paper we consider the extent to which the achievements of the Canadian approach to health care funding have been maintained in the presence of increasing attention to cost containment. Multivariate analyses are used to (a) explain variations in utilization of family physician services among the population and (b) explore the relationship between utilization and need for periods of differing economic circumstances. We observe that the relative importance of differences in need in explaining variations in use among the population was less in the period when cost containment was of greater concern. These findings indicate that policymakers cannot assume that removing financial barriers to access to service, although important in achieving a more equitable distribution of service utilization, may be sufficient to sustain such distributions during time of constraint.

This paper reviews the factors which make non-immune pregnant women particularly vulnerable to falciparum malaria and examines the problems of adequately protecting them in relation to current control strategies. Women are most at risk in areas of high and continuous transmission, particularly during their first pregnancy, and also under conditions of unstable malaria which do not permit immunity to develop. Chemoprophylaxis is recommended for pregnant women in holoendemic and hyperendemic areas in Africa and Papua New Guinea. Chloroquine is safe, but drug resistance problems are beginning to limit its utility. Distribution is a formidable problem in rural areas with a poorly developed health care infrastructure, and research studies reveal widespread ignorance and lack of motivation. In countries in which primary health care systems are fairly well developed, and where malaria transmission is relatively less intense, the emphasis is on early diagnosis and treatment of cases. The assumption is made that women and men have equal access to medical facilities. The preponderance of reported cases among adolescent and adult males in some areas has been attributed solely to the well-known greater occupational risks in some traditionally male activities. Two recent studies, however, suggest that underprivileged women, weighed down by domestic chores, do not readily attend clinics at some distance from home, and therefore are liable to be missed in passive surveillance. It is essential that services within the village should be strengthened, but there are problems in implementation. Lacunae in existing knowledge are discussed.

This paper undertakes both a macro- and micro-scale analysis of the influences exerted by the health care system on patterns of hospitalization. The health disorder of diabetes mellitus is used as the case study and the analyses are based on New Zealand data sets. The article first examines the extent to which both the supply and organization of primary and secondary health care affect rates of hospitalization. The macro-scale analysis investigates the applicability of Roemer's Law to regional variations in diabetes hospitalization. The organizational control of hospital utilization via doctor gatekeeping functions and interaction between health services are then examined at the local level. This analysis assumes a population based approach using the Canterbury Register of Insulin-treated diabetic persons as the study population. Diabetes discharge rates were found to be most highly correlated with hospital bed supply in 5 of the 8 years studied (1979-1986). Stepwise regression analysis indicated area rates of diabetes hospitalization were significantly influenced by resource factors even after controlling for differences in the socio-demographic characteristics of the area populations. This confirmed the presence of Roemer's Law at the aggregate level with rates of diabetes hospitalization appearing to have more to do with the availability of medical resources than to population needs. At the local level, hospital admission patterns were found to vary by general practitioner age, practice type found to vary by general practitioner age, practice type and diabetic caseload. Overall, insulin-treated diabetic patients most likely to be hospitalized were those in the care of young doctors new to general practice, and those who attended doctors who had small diabetic caseloads. Solo practitioners had the lowest rates of patient hospitalization. There were marked disparities in patient access to specialist diabetes education and clinical outpatient services by patient age,duration of diabetes and attendance on primary care. Overall, no significant differences were found in the propensity for hospitalization between users and non-users of these specialist services. This does not imply however, service ineffectiveness but rather is indicative of the complexity of the local diabetes care organization and the differing needs of the insulin-treated diabetic population within the community as a whole.

This study of the costs, quality and financial equity of primary health services in Ecuador, based on 1985 data, examines three assumptions, common in international health, concerning Ministry of Health (MOH) and Social Security (SS) programs. The assumptions are that MOH services are less costly than SS services, that they are of lower quality than SS services, and that MOH programs are more equitable in terms of the distribution of funds available for PHC among different population groups. Full costs of a range of primary health services were estimated by standard accounting techniques for 15 typical health care establishments, 8 operated by the MOH and 7 by the rural SS program (RSSP), serving rural and peri-urban populations in the two major geographical regions of Ecuador. Consistent with the conventional premise, MOH average costs were much lower than RSSP costs for several important types of services, especially those provided by physicians. Little difference was found for dental care. The lower MOH physician service costs appeared to be attributable primarily to lower personnel compensation (only partially offset by lesser productivity) and to greater economies of scope. Several measures of the quality of care were applied, with varying results. Based on staff differences and patterns of expenditures on resource inputs, notably drugs, RSSP quality appeared higher, as assumed. However, contrary to expectation, a questionnaire assessment of staff knowledge and procedures favored the MOH for quality. Program equity was judged in terms of per capita budgeted expenditures (additional measures, such as the likelihood of receiving necessary care, would have required household survey data beyond the scope of this program-based study). The results support the assumption of greater MOH financial equity, as its program reveals less variation in budgeted expenditures between different population groups covered. Additional evidence of equity, using other indicators, would be helpful in future research. The paper's findings have policy implications not only for Ecuador's health sector but also for policy-makers in other countries at similar levels of socioeconomic development. These implications are spelled out in order to guide officials wrestling with issues of efficiency, quality, and equity as they search for the best use of scarce resources to promote health. Key words--costs, efficiency, equity, quality

Introduction: Most diagnoses of genital chlamydia infection in Queensland are made by general practitioners (GPs). This study aimed to assess GP attitudes to and knowledge of contact tracing in rural North Queensland. Method: A single page questionnaire mailed to a database of 65 GPs in May 2007 Results: Nearly all respondents (42/43, 97.7%) 'always' or 'mostly' told patients to advise their contacts to seek medical treatment. More than half (24/44, 54.5%) felt that contact tracing was 'sometimes' or 'never' the responsibility of GPs. Around half of respondents (19/39, 48.7%) thought that the local public health unit staff were conducting contact tracing, which is not actually the case. Conclusion: There is lack of clarity surrounding the respective roles and responsibilities of sexual health units, public health units and GPs regarding contact tracing for chlamydia infection. Implications: GPs would benefit from education clarifying current contact tracing procedures, methods and resources. Keywords: chlamydia trachomatis, contact tracing, partner notification doi: 10.1111/j.1753-6405.2008.00256.x

How do medical residents organize their work in settings where queue demands are heavy and resources are limited? Under such conditions, a queue theory would predict the delivery of care that is indifferent to clients' needs or that gets rid of clients as quickly as possible. In an exploratory case study of medical residents in a Veterans Administration oupatient clinic, we found instead that the medical residents' work was characterized by a high level of professional commitment: they provided thorough medical examinations and attempted to expedite patient care in other ways. We attribute the residents' professional ethos to opportunities provided in the VA hospital to learn the craft of routine medicine and to be directly responsible for patient care; such opportunities were not available in other settings.

This paper presents two different yet complementary on-going studies related to the understanding of the mechanisms leading to social inequalities in health. The first part is devoted to a differential morbidity survey held in southern Belgium. It confirms that striking differences exist in the period around birth between social categories, and between the three districts under study. In a multivariate approach, differences remain between the social categories and between the district samples, which classically studied socio-demographical, behavioural and medical characteristics cannot fully explain. The role of cultural factors is analysed and discussed through the concept of 'health culture' and alternative hypotheses are reviewed in the light of the results. The second part reviews the studies conducted on the so-called avoidable mortality in the EEC and more specifically in Belgium. The concept of avoidable mortality is discussed, as well as its utility from the standpoint of the present concern on social inequalities. Differences between EEC countries are large, and even within Belgium there are important disparities between the districts. The role of health care supply has not been demonstrated yet in these two contexts. For Belgium, it appears that a major part of the unequally distributed mortality is constituted by causes of death considered as avoidable. Moreover, the most discriminating causes of death are overrepresented in socially deprived districts. The two perspectives are confronted in order to delineate perspective for future research and operational outcomes for policy making and interventions.

Proposals that medical malpractice claims be removed from the tort system and processed in an alternative system, known as administrative compensation or 'health courts,' attract considerable policy interest during malpractice 'crises,' including the current one. This article describes current proposals for the design of a health court system and the system's advantages for improving patient safety. Among these advantages are the cultivation of a culture of transparency regarding medical errors and the creation of mechanisms to gather and analyze data on medical injuries. The article discusses the experiences of foreign countries with administrative compensation systems for medical injury, including their use of claims data for research on patient safety; choices regarding the compensation system's relationship to physician disciplinary processes; and the proposed system's possible limitations.

Objective: To assess consent to record linkage, describe the characteristics of consenters and compare self-report versus Medicare records of general practitioner use. Method: Almost 40,000 women in the Australian Longitudinal Study on Women's Health were sent a request by mail for permission to link their Medicare records and survey data. Results: 19,700 women consented: 37% of young (18-23 years), 59% of mid-age (45-50 years) and 53% of older women (70-75 years). Consenters tended to have higher levels of education and, among the older cohort, were in better health than non-consenters. Women tended to under-report the number of visits to general practitioners. Conclusions: Record linkage of survey and Medicare data on a large scale is feasible. The linked data provide information on health and socio-economic status which are valuable for understanding health service utilisation. Implications: Linked records provide a powerful tool for health care research, particularly in longitudinal studies.

One of the main objective of Dutch Government policy on primary health care concerns equal regional dispersion of health care provisions. At this moment these provisions are geographically not equally distributed when measured in terms of the number of inhabitants per practising professional in primary health care. In this paper the current patterns of dispersion of five professional groups are described. The groups concerned are the general practitioners, dentists, physiotherapists, pharmacists and midwives. These patterns are mainly a consequence of market forces because the professionals have had the freedom to choose where to practise their profession until recently. These decisions are affected by the 'place utility' of an area. In this paper place utility is conceived as being determinated by the opportunities of an area to earn a living and the amenities of an area as residential and living-environment. These concepts are operationalized by a set of independent variables. In order to understand the (differences between the) patterns of dispersion of the professional groups concerned multiple regression-analysis has been used, of which the results are compared to the hypotheses formulated. Key words--primary health care, regional dispersion, health professionals, the Netherlands

A conceptual framework for planning reproductive health services for refugees is presented for use by those involved in planning field activities. Secondary sources of data are recommended to describe pre-existing patterns and trends in reproductive health status and likely determinants of any change in status, for populations which have been subsequently affected by conflict. The interaction between these patterns and the conflict itself is then analyzed, taking into account the shift in health status and service availability as the conflict progresses through various recognized phases. The potential impact of conflict is thus hypothesized in order to make initial plans for incorporating reproductive health services into standard relief packages. Two case studies are presented: Rwanda demonstrates the use of the framework in a relatively short but dramatic conflict, for which there was also substantial prior evidence on reproductive health status; Cambodia is used, in contrast, to demonstrate the use of the framework in a much more complex conflict which has been occurring over the last 20 years. Keywords: Refugee; Reproductive health; Needs assessment; Rwanda; Cambodia

This paper compares structural components of medical delivery in two major systemwide reform strategies in the United States. Commonly portrayed in terms of opposing ideologies of planning vs. market reform, regional organization and managed competition have promoted similar structural elements and geographic configurations. They both support growth of institution-based specialized teams and hospital consolidation. They both differentiate hospital care into vertically integrated levels, and develop regions as the key production and market area for organized delivery systems. System-wide management or regulation in each has tried to control allocation of resources, capital investment, and competition. Developed in the context of large-scale industrial production, these components have inherent economic dynamics and together they shape the market structure of medical care. The final section briefly considers the locus of power in the two reform approaches and the implication for choosing mechanisms of reform. It also notes that despite their rhetoric, the two strategies do not shape their services according to information about population benefit. The conclusion points out that the commonalities in structure and power demonstrate the dominance of economic organization in medical reform and contribute to the wide acceptance of this business form of organization as an international model. Keywords: Regional planning; Managed competition; Organized delivery systems; Industrial model of medicine; Health care reform

Compulsory medical service programs for physicians and other health care professionals have been installed in developing countries around the world. The underlying assumption for the creation of these programs is that the increased presence of physicians will improve the health status of rural populations which exhibit higher rates of morbidity and mortality compared to urban populations. This assumption, however, has been challenged by recent evaluative studies of compulsory service programs in Latin America. This paper reports on the physician's perspective of Ecuador's compulsory service program, known as medicatura rural. based on responses to a self-administered questionnaire completed by 127 physicians who had fulfilled or were currently fulfilling their medicatura rural requirement, in-depth interviews with physicians and other officials, and visits to several rural placement sites, the paper examines some of the fundamental programmatic and logistical problems that have impeded the successful implementation of the program since its inception in 1970. While the majority of the physicians reported that the medicatura rural experience was both professionally and personally rewarding, many view the program as conceptually flawed with respect to its goal of improving the health status of rural communities. The physicians' suggestions for improving the medicatura rural, which elucidate some of the program's basic conceptual flaws and reflect the criticisms of compulsory' medical programs in other Latin American countries, are discussed. Finally, Ugalde's (1988) recommendation for replacing compulsory medical service programs with a 'rural health corps' is considered. Key words - compulsory medical service, Latin America, rural health

The care and services available for HIV patients and how these can be improved are studied. The public programs currently available to HIV patients include Medicaid, Medicare and the Housing Opportunities for People with AIDS Program. However, the government and AIDS community can improve HIV-related care by addressing issues such as the links between cost and quality of care and the need to coordinate entitlement programs.