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Background: The use of administrative databases in vascular injury research has been increasing, but the validity of the diagnosis codes used in this research is uncertain. We assessed the positive predictive value (PPV) of International Classification of Diseases, tenth revision (ICD-10), vascular injury codes in administrative claims data in Ontario. Methods: We conducted a retrospective validation study using the Canadian Institute for Health Information Discharge Abstract Database, an administrative database that records all hospital admissions in Canada. We evaluated 380 randomly selected hospital discharge abstracts from the 2 main trauma centres in Toronto, Ont., St. Michael's Hospital and Sunnybrook Health Sciences Centre, between Apr. 1, 2002, and Mar. 31, 2010. We then compared these records with the corresponding patients' hospital charts to assess the level of agreement for procedure coding. We calculated the PPV and sensitivity to estimate the validity of vascular injury diagnosis coding. Results: The overall PPV for vascular injury coding was estimated to be 95% (95% confidence interval [CI] 92.3-96.8). The PPV among code groups for neck, thorax, abdomen, upper extremity and lower extremity injuries ranged from 90.8 (95% CI 82.2-95.5) to 97.4 (95% CI 91.0-99.3), whereas sensitivity ranged from 90% (95% CI 81.5-94.8) to 98.7% (95% CI 92.9-99.8). Conclusion: Administrative claims hospital discharge data based on ICD-10 diagnosis codes have a high level of validity when identifying cases of vascular injury. Level of evidence: Observational Study Level III. Contexte: L'utilisation des bases de donnees administratives pour la recherche sur les lesions vasculaires est en hausse, mais la validite des codes diagnostiques utilises dans ces recherches est incertaine. Nous avons evalue la valeur predictive positive (VPP) des codes de lesions vasculaires de la dixieme edition de la Classification internationale des maladies (CIM-10) qui figurent dans une base de donnees administrative ontarienne. Methodes: Nous avons realise une etude de validation retrospective a partir de la base de donnees de l'Institut canadien d'information sur la sante (ICIS) sur les conges des patients, une base de donnees administrative qui enregistre toutes les hospitalisations au Canada. Nous avons evalue 380 conges hospitaliers de 2 grands centres de traumatologie de Toronto, en Ontario, soit l'Hopital St. Michael's et le Centre des sciences de la sante Sunnybrook, entre le 1er avril 2002 et le 31 mars 2010. Nous avons ensuite compare ces dossiers aux dossiers hospitaliers des patients correspondants pour verifier la concordance des codes attribues aux interventions. Nous avons calcule la VPP et la sensibilite pour estimer la validite des codes diagnostiques appliques aux lesions vasculaires. Resultats: La VPP globale pour les codes de lesions vasculaires a ete estimee a 95 % (intervalle de confiance [IC] de 95 % 92,3-96,8). Parmi les groupes de codes attribues aux lesions affectant le cou, le thorax, l'abdomen, les membres superieurs et inferieurs, la VPP a varie de 90,8 (IC de 95 % 82,2-95,5) a 97,4 (IC de 95 % 91.0-99,3), tandis que la sensibilite a varie de 90 % (IC de 95 % 81,5-94,8) a 98,7 % (IC de 95 % 92,9-99,8). Conclusion: Les donnees administratives sur les conges hospitaliers basees sur les codes diagnostiques de la CIM 10 ont un degre de validite eleve pour ce qui est des lesions vasculaires. Niveau de preuve: Etude d'observation Niveau III., Administrative claims databases are an important source of data for epidemiological research. These databases are often large and contain information on patient hospital admissions, emergency department visits, clinic visits and [...]

The article discusses how important it is for individuals wishing to choose a high-quality hospital to keep several factors in mind. The case of a previously healthy 37-year-old man diagnosed with prinzmetal angina is highlighted to better understand the problems faced by patients while having to change physicians and hospitals.

Purpose: A national quality report card for nursing homes, Nursing Home Compare, has been published since 2002. It has been shown to have some, albeit limited, positive impact on quality of care. The objective of this study was to test empirically the hypothesis that nursing homes have responded to the publication of the report by adopting cream skimming admission policies. Design and Methods: The study included all non-Medicare newly admitted patients to all Medicare- and Medicaid-certified nursing homes nationally during the 2001-2005 period. Using the Minimum Data Set data, we calculated for each quarter several admission cohort characteristics: average number of activity of daily living limitations and percent of residents admitted with pain, with pressure ulcers, with urinary incontinence, with diabetes, and with memory limitations. We tested whether residents admitted in the postpublication period were less frail and sick compared with residents admitted in the prepublication period by estimating fixed facility effects longitudinal regression models. Analyses were stratified by nursing home ownership, occupancy, reported quality ranking, chain affiliation, and region. Results: Evidence for cream skimming was found with respect to pain and, to a lesser degree, with respect to memory limitation but not with respect to the 4 other admission cohort characteristics. Implications: Despite the theoretical expectation, empirical evidence suggests only a limited degree of cream skimming. Further studies are required to investigate this phenomenon with respect to other admission cohort characteristics and with respect to post-acute patients. Key Words: Nursing homes, Quality, Report cards, Cream skimming doi: 10.1093/geront/gnp062

Objectives. We evaluated an intervention to support health workers after training in Integrated Management of Childhood Illness (IMCI), a strategy that can improve outcomes for children in developing countries by encouraging workers' use of evidence-based guidelines for managing the leading causes of child mortality. Methods. We conducted a randomized trial in Benin. We administered a survey in 1999 to assess health care quality before IMCI training. Health workers then received training plus either study supports (job aids, nonfinancial incentives, and supervision of workers and supervisors) or usual supports. Follow-up surveys conducted in 2001 to 2004 assessed recommended treatment, recommended or adequate treatment, and an index of overall guideline adherence. Results. We analyzed 1244 consultations. Performance improved in both intervention and control groups, with no significant differences between groups. However, training proceeded slowly, and low-quality care from health workers without IMCI training diluted intervention effects. Per-protocol analyses revealed that workers with IMCI training plus study supports provided better care than did those with training plus usual supports (27.3 percentage-point difference for recommended treatment; P Conclusions. IMCI training was useful but insufficient. Relatively inexpensive supports can lead to additional improvements. doi:10.2105/AJPH.2008.134411)

Objectives. We sought to ascertain the types of ethical challenges public health practitioners face in practice and to identify approaches used to resolve such challenges. Methods. We conducted 45 semistructured interviews with public health practitioners across a range of occupations (e.g., health officers, medical directors, sanitarians, nurses) at 13 health departments in Michigan. Results. Through qualitative analysis, we identified 5 broad categories of ethical issues common across occupations and locations: (1) determining appropriate use of public health authority, (2) making decisions related to resource allocation, (3) negotiating political interference in public health practice, (4) ensuring standards of quality of care, and (5) questioning the role or scope of public health. Participants cited a variety of values guiding their decision-making that did not coalesce around core values often associated with public health, such as social justice or utilitarianism. Public health practitioners relied on consultations with colleagues to resolve challenges, infrequently using frameworks for decision-making. Conclusions. Public health practitioners showed a nuanced understanding of ethical issues and navigated ethical challenges with minimal formal assistance. Decision-making guides that are empirically informed and tailored for practitioners might have some value. (Am J Public Health. 2009;99:369-374. doi: 10.2105/AJPH.2008.137588)

The evidence-based practice (EBP) movement in medicine has permeated and affected a wide array of health and allied health care disciplines, and the field of rehabilitation is no exception. The purpose of this paper is to provide rehabilitation professionals up-to-date information about the defining characteristics and available resources of EBP for healthcare and rehabilitation practices, the critical issues that surround this movement, and the implications of this movement for the field of rehabilitation., The concept of evidence-based practice (EBP) has assumed a central position in health and behavioral health care disciplines. Frequently defined as the conscientious, explicit, and judicious use of current best [...]

This paper reports findings of a study in 2004 of the development of specialist services for older people in the National Health Service (NHS) in England, as recommended in the Department of Health's National Service Framework for Older People (NSF-OP). The study was funded by the Department of Health as part of a programme of research to explore the Framework's implementation. Information was collected through a questionnaire survey about the nature of specialist developments at three levels of the NHS: strategic health authorities (SHAs), provider Trusts, and service units. This produced an overview of developments and a frame from which to select detailed case studies. Analysis of the survey data showed that there were variations in the way that the NSF-OP was being interpreted and implemented. In particular, there was inconsistency in the interpretation of the NSF-OP's anti-ageism standard; some concluded that the strategy discouraged services exclusively for older people, others that it encouraged dedicated provision for them. The tension between creating age-blind and age-defined services was played out in the context of existing service structures, which had been shaped over decades by many local and national influences. These conceptual and historical factors need to be taken into account if services are to change, as developments are shaped by 'bottom-up' local processes as well as 'top-down' policy initiatives. In particular, the tension inherent in the NSF-OP between negative and positive ageism, and its varied interpretations at local levels needs to be taken into account when evaluating progress in implementation. KEY WORDS--older people, specialist services, National Service Frameworks.

This paper reports the results of a comparison between two different methods of examining quality in outpatient services in a developing country. Data from rural and urban Tanzania are used to compare the measures of quality collected by direct clinician observation (DCO) (where clinicians are observed in the course of their normal consultations) and vignettes (unblind case studies with an actor). The vignettes are shown to exhibit a strong connection between the inputs provided during consultation (rational history taking, physical examination and health education) and the ability of the clinician to properly diagnose the presented illness. However, the inputs provided in vignettes are not well correlated with the inputs provided in DCO, suggesting that the inputs provided in the vignette are not well correlated with the inputs that would be provided in an actual consultation. We conclude that since vignettes do not appear to be measuring what would be provided in an actual consultation they are not a good measure of quality. Instead, we suggest that vignettes and DCO be used simultaneously. We show how the scores obtained using vignettes in conjunction with DCO can be used to improve the reliability of DCO and therefore our estimates of actual clinician quality. Keywords: Direct clinician observation; Vignettes; Health services quality; Tanzania

The complexity and cost of health systems requires innovative forms of organization to provide accessible health services of an acceptable quality and at an acceptable cost. Interorganizational collaboration (IoC) is an innovation to increase the availability of organizational resources, improve service effectiveness, and improve access to health care. In Pakistan, a weak health system and little collaboration limit access, especially of women and children, to health services. Many nongovernmental organizations (NGOs) provide primary health care to the very poor, and some appear to collaborate to varying degrees; however, this has not been systematically analyzed. The purpose of this qualitative research, the first scientific study of collaboration between NGOs providing health services in Pakistan, was to describe collaboration between three pairs of NGOs providing community-based health services to women in Karachi. A longterm goal is to build a basis for future research linking IoC to access to health care and health outcomes. Findings indicated that collaboration was strongest when there was willingness to cooperate, a need for expertise and funds, and adaptive efficiency. In Pakistan's complex social environment, collaboration tended to be stronger when there was fairly high organizational formalization. Broader IoC appears to be positively associated with women's access to health care. Recommendations are made for future research, education, and management. Keywords: Nongovernmental organizations (NGOs); Interorganizational collaboration; Health care access; Women's health; Health services; Karachi; Pakistan

A growing body of literature in geography and other social sciences considers the role of place in the provision of healthcare with particular interests emerging around the role of the psychological, social and cultural aspects of place in care provision. As healthcare stretches increasingly beyond the traditional four walls of the hospital, so questions of the role of place in practices of care become ever more pertinent. In this paper, we examine the relationship between place and practice in the care and rehabilitation of older people across a range of settings, using qualitative material obtained from interviews and focus groups with nursing, care and rehabilitation staff working in hospitals, clients' homes and other sites in England. By analysing their testimony on the characteristics of different settings, the aspects of place which facilitate or inhibit rehabilitation and the ways in which place mediates and is mediated by social interaction, we consider how various dimensions of place relate to the power-inscribed relationships between service users, informal carers and professionals as they negotiate the goals of the rehabilitation process. We seek to demonstrate how the physical, psychological and social meanings of place and the social processes engendered by the rehabilitation encounter interact to produce landscapes that are more or less therapeutic, considering in particular the structuring role of state policy and formal healthcare provision in this dynamic. Keywords: Intermediate care; Older people; Therapeutic landscape; Rehabilitation; Community care; UK

This paper presents results from a qualitative analysis of official documents dealing with the deregulation of the Danish medicine distribution system, 2001. In an attempt to clarify how consumerism within health care is manifested in policy, this study explores how central actors in the political process explicitly referred to the needs, interests and problems of the users of medicine. The results show that explicit references to the users of medicine by central actors in the political process were limited. Based on this we argue that in this case, although the debate centred on liberal ideas it seems as if chief values of classic liberalism were lost in the process of translating a political idea into political practice. Keywords: Medicine Distribution System; Consumer Participation; Health Policy; Health Care Reform; Denmark

In many countries health policy has been guided by a focus on the supply side factors of access to health care, a lot of attention being directed at the availability of services. This paper concentrates on the demand side of access and investigates relational factors that may limit people's subjective choice sets or their freedom to utilise health services, emphasising that relations between service providers and individuals are based on an interchange of information. It develops an argument for health communication strategies based on an interactive exchange of information as a means of improving access and is intended as a conceptual basis for further debate. Trust assumes a key position within this transactional process of information exchange or communicative interaction. Information may enlarge individual choice sets and increase the freedom to use health care; it serves as a stimulus for access. The paper argues that trust plays a role in the utilisation of provided information. Trust emerges as a prerequisite of the effectiveness of information with regard to access. A discussion of the origins of trust shows that, while trust enhances communicative interaction, it is the process of communicative interaction that generates trust in the first place. Culturally diverse societies are often low-trust environments. The paper analyses the driving forces of trust and distrust in health care within these societies and delineates barriers for the individual and the community to the transfer of information. Specific characteristics of health communication turn out to be key determinants of access. In conclusion, principles for health policy on equity and information are derived which are rooted in a distinctive notion of democratic societal structure. Keywords: Access; Health communication; Information; Trust

This paper explores the lived experiences and the identity processes attached to attendance at free clinics. It draws on a qualitative study of 94 patients and 37 professionals who were interviewed at four free clinics in France. Since these facilities are for the poor and for people without health coverage, attendance reflects a medical experience as well as an experience of assistance, both of which have an impact on healthcare utilisation. Nevertheless, the meaning attached to the recourse to free clinics and the patients' lived experiences change over time and depend on interactions with clinic staff. This study proposes a typology of care recourse modes (occasional, regular and inconsistent attendance) crossed with different types of lived experiences. Occasional attendance and distant patient-professionals relationships, often due to the humiliation that some people feel when they have to ask for social assistance, characterise the first time people have recourse to care. Patients commit to regular follow-ups only when they have come to terms with their position in the medical and assistance system, doing so by rationalising and adjusting their identity. Our aim in discussing our findings is to gain greater insight into the utilisation of healthcare by different population groups and in different contexts. Keywords: Healthcare utilisation; Free clinics; Moral career; Doctor-patient relationship; Poverty; France

Based on anthropological field research (1997-2000) within the Department of Health and Community Services in the Northern Territory in Australia, this paper explores the lingering features of colonial logic in the pastoral work of public health workers in the Northern Territory of Australia. The public health professionals drawn to work in this space are determined to remedy what is wrong with culturally acceptable solutions. But viewed from an anthropological perspective, the way in which health professionals conceptualise the problems they need to solve ultimately serves to reinforce the reality of the need for their continued tutelary presence. This paper aims to draw out the complex ways in which this interventionary effect is secured, concentrating in particular on the role played by progressive ideologies of participatory development and information sharing. It argues that through a complex process of forgetting, the otherwise innocuous gestures of public health goodwill recreate a mandate for more public health intervention. This is not a simple moral tale where analysts can easily identify good and bad practices and thus distance themselves from the difficulties involved. Rather, by emphasising the honest commitments to improvement in situations of mass illness and preventable disease that health professionals bring to their work, and the burden they bear in being conscious of the recent colonial past, the paper aims to avoid the judgement that this sort of work is easy to get right. Keywords: Aborigines; Public health; Postcoloniality; Cross-cultural pedagogy; Australia

To better understand the distribution of resources and health care consumption patterns in different geo-ethnic and socio-economic settings, we sought to describe the patterns of illness, care-seeking behavior and health services utilization in Hong Kong compared to the US and UK. Data were derived from the 2002 Hong Kong Thematic Household Survey covering 31,762 non-institutional and institutional residents, representing 6,504,255 persons after applying population weights. Of 1000 individuals during a 1-month period, 567 reported symptoms, 512 of whom considered seeking health care. Four hundred and forty persons visited western allopathic medical practitioners, with 372 (84.5%) in primary care and 68 (15.5%) in specialty care. There were 54 visits to traditional Chinese medical practitioners and 16 emergency room episodes. Seven individuals were hospitalized in community hospitals and on average one in 1000 were admitted to a tertiary medical center. Ninety out of the 567 who experienced symptoms undertook self-management strategies, which included over-the-counter western allopathic medications (n = 54) or traditional Chinese remedies (n = 14) or both (n = 2), dietary modification (n = 1) and rest (n = 15). We have mapped the ecology of health care in Hong Kong. Monthly prevalence estimates were remarkably similar to US figures for hospital-based events, whereas there was evidence of apparent, substantial 'over-consumption' of ambulatory, community-based care. Our results also indicate that the local community's care-seeking orientation still very much favors western allopathic medicine over traditional Chinese therapy, at least for acute illness episodes. Keywords: Hong Kong; Health services utilization; Western allopathic medications; Traditional medicine

Epidemiological, demographic and environmental crises, transition to a new political regime and exceptionally severe economic crises were powerful stimuli to health sector reform in Russia. The Russian Federation responded by introducing medical insurance whilst decentralising public administration. Yet despite intense contextual pressures to do so and a new policy climate, Russian hospitals found it difficult to reprofile services and reallocate their resources. A case study analysing governance structures in Sverdlovsk oblast reveals that medical insurance created incentives to reduce costs by reducing bed-days, but if hospitals did so they would lose money under the formulae through which decentralised local government still allocated around three-quarters of hospital income. If instead hospitals tried to increase budgetary income by increasing numbers of bed-days, the insurance system would penalise them. This specific form of policy mess can be called 'governance in gridlock'. The juxtaposition of two overlapping but incompatible sets of governance structures practically immobilised official hospital management systems. It is as one-sided to blame residues of the Soviet system for this gridlock as it is to blame the medical insurance system. Gridlock resulted from the interaction of the two, a problem to which all health system reform is potentially vulnerable. Keywords: Decentralisation; Governance; Gridlock; Health insurance; Hospital management; Russia; Soviet Union

The paper explores the attitudes of medical physicians towards adverse incident reporting in health care, with particular focus on the inhibiting factors or barriers to participation. It is recognised that there are major barriers to medical reporting, such as the 'culture of blame'. There are, however, few detailed qualitative accounts of medical culture as it relates to incident reporting. Drawing on a 2-year qualitative case study in the UK, this paper presents data gathered from 28 semi-structured interviews with specialist physicians. The findings suggest that blame certainly inhibits medical reporting, but other cultural issues were also significant. It was commonly accepted by doctors that errors are an 'inevitable' and potentially unmanageable feature of medical work and incident reporting was therefore 'pointless'. It was also found that reporting was discouraged by an anti-bureaucratic sentiment and rejection of excessive administrative duties. Doctors were also apprehensive about the increased potential for managers and non-physicians to engage in the regulation of medical quality through the use of incident data. The paper argues that the promotion of incident reporting must engage with more than the ubiquitous 'culture of blame' and instead address the 'culture of medicine', especially as it relates to the collegial and professional control of quality. Keywords: Patient safety; Incident reporting; Blame; UK

Individual patient randomized trials are the gold standard for assessing the effects of health care evaluations. However, individual randomization may not be possible for practical, logistical, ethical, or political reasons, for example, when evaluating health care professional and organizational behavior change interventions. Under such circumstances, cluster randomized trials are commonly used. This article discusses the practical and ethical issues in the design, conduct, and analysis of cluster randomized trials of professional behavior and organizational change strategies using examples from two primary studies evaluating health care provider behavior change strategies. Cluster randomized trials are commonly used in health care. They raise distinct ethical and methodological issues that have rarely been adequately addressed in studies to date. Keywords: cluster randomized trials; implementation research; interventions; dissemination and implementation interventions; COmputerised Guidelines Evaluation in the NorTh of England (COGENT)