New information from the State Committee on Statistics of the USSR

Selected data concerning the USSR are presented. They concern vital statistics by republic for 1989 for rural and urban areas, birth order, life expectancy by sex, and population change and vital statistics for cities with a population over one million.     

Education and the professionals. Some aspects of innovation in medical education adopted by Ahfad University for Women

This article describes the establishment in 1990 of a School of Medicine at Ahfad University for Women in Sudan. The school was premised on the view that women doctors would have a better opportunity to affect and improve women's health than men doctors. The curriculum is innovative and relies on a community orientation and a problem-solving approach. Medicine and health are taught in a holistic way. The new approach is rooted in the Alma Ata Declaration in 1978 of Health for All by the year 2000. The new method of delivery of medical care in the School of Medicine is based on the promotion of health through health education, prevention of disease, proper nutrition, provision of a safe water supply, attention to maternal/child health and family planning, and attention to the treatment of endemic diseases. In order to teach primary health care, medical schools must change their practices. Delivery of health care will have to be changed. New curriculum approaches emphasize learning objectives in each of the teaching modules and small group teaching. Integrated learning means the separate disciplines of medicine are taught as a whole multidisciplinary unit. Case management learning has the potential for increasing motivation and the ability to discover the knowledge needed to solve the problem. McMaster University relies on a problem-oriented approach to medical education that prepares the student for coping with changes in medical knowledge in the future. The challenge for educators is to create an efficient and comprehensive curriculum that will prepare a doctor for lifelong learning. Health settings have also changed to deemphasize sophisticated hospital settings in favor of community-based health centers. Ahfad University is the only one of its kind in Sudan. Medical education includes 6 years of schooling divided into 3 phases.     

IOM/UNFPA project on emigration dynamics in developing countries

The author briefly reviews a special section of papers in this issue of International Migration. The papers focus on aspects of a project on emigration dynamics in developing countries.     

Accounting for the transition from inpatient to outpatient surgery

This article reports on some of the factors that have advanced and impeded hospital progress in moving from inpatient to outpatient surgery. Early on, patients, physicians, and hospital administrators all agreed that outpatient surgery had an intuitive appeal. Patients liked it because they didn't have to go in the hospital. Physicians liked it because they could get in and out of the outpatient surgery center more easily than the main hospital operating room. Administrators recognized the inherent appeal of outpatient procedures but were unable or unwilling to switch services from inpatient to outpatient for a variety of reasons. First, empty hospital beds and diminished scope of inpatient operations are a threat to the power of administrators. Moving surgery from inpatient to outpatient settings reduces inhouse operations. Second, reimbursement incentives were definitely in favor of continued inpatient care long after technology was in place for outpatient care. The third and most critical reason was that cost data on outpatient operations were just not available for making decisions on when to move into the outpatient setting. This review of the literature was intended to document the lack of relevant cost-based accounting. Instead, many other factors that more directly slowed progress were encountered. More than anything, this illustrates the erratic course of progress in health care reform.     

When push comes to shove: implementing VBAC practice guidelines

The dramatic increase in U.S. cesarean sections over the past two decades has been significantly driven by repeat C-sections. In response to this trend, clinical guidelines recommending vaginal birth after cesarean-section (VBAC) have been promulgated by national organizations. Adherence to these guidelines would reduce the number of repeat C-sections, lower the overall C-section rate, and improve both the quality and the cost of health care. While these guidelines have received professional endorsement, their implementation has been clouded by issues of patient acceptance and provider payment. To examine implementation of these guidelines by health care organizations, the authors surveyed 156 members of the American College of Physician Executives to determine their policies, practices, and attitudes toward VBAC guidelines. Those surveyed generally were medical directors in HMOs, hospitals, and other practice settings. The findings indicate that the health care organizations represented by these physician executives have not consistently implemented VBAC guideline and that they are reluctant to hold physicians, their patients, or hospitals accountable for the financial, utilization, and quality impact of the elective decision ot to pursue appropriate VBACs. We conclude that, even when widely accepted, clinical practice guidelines may be ineffective in reducing the costs or improving the quality of medical care.