Herding stats: the quality measurement dilemma

All over the country, millions of research dollars are being spent to devise an effective way of measuring quality that could be standardized in health care, and hospitals and managed care companies are experimenting with a variety of quality tools, trying to document what they now can only perceive as improvement. Experts are divided on what works best, but all applaud and embrace the efforts. In this special report, several of them discuss their views on what works, and what doesn't work, in the exploding field of health care quality measurement.     

Keeping the "care" in managed care: the importance of the therapeutic relationship and psychosocial factors in the managed care setting

There is much truth in the adage that "the more things change, the more they stay the same." Nowhere does this seem more apparent than in health care where, amidst monumental reconfiguration, basic foundations of physician-patient relationships and attention to the impact of psychosocial factors on health and health care delivery remain as critical influences. While the importance of the therapeutic relationship and the influence of psychosocial factors in medical care has been clear in traditional systems of delivery, these factors may be even more critical in managed care systems. These emphases must be incorporated by design, however, and not left to default.     

Emigration dynamics of eastern African countries

This examination of emigration dynamics focuses on 13 countries extending from Eritrea to Zimbabwe and Mozambique on the eastern African mainland and on 5 Indian Ocean island nations. The first part of the study looks at the temporal, spatial, and structural perspectives of emigration dynamics. Part 2 considers international migration in the region according to Appleyard's typology (permanent settlers, labor migration, refugees, and illegal migrants) with the additional category of return migration. Measurement issues in emigration dynamics are discussed in part 3, and the demographic/economic setting is the topic of part 4. The demographic factors emphasized include spatial distribution, population density, population structure, population dynamics, demographic transition, and the relationship between internal and international migration. Other major topics of this section of the study are the economic base, the human resource base, population and natural resources, the sociocultural context (emigration, chain migration, return migration, and migration linkages and networks), political factors (including human rights, minority rights and security, regional integration and economic cooperation, and the impact of structural adjustment programs), and a prediction of future emigration dynamics. It is concluded that refugee flows remain a major factor in eastern African countries but the development of human resources in the northern portion of the region indicates development of potential labor migration from this area. Data constraints have limited measurement of emigration in this region and may contribute to the seeming indifference of most eastern African countries to emigration policies. Emigration in this region has been triggered by deteriorating economic and political conditions and is expected to increase.     

Drawing households and other living spaces in the process of assessment and psychotherapy

This paper introduces a drawing technique developed by the author for use in the assessment and treatment of individuals and families. The client is invited to draw a floor plan of his or her home or apartment, or an aerial view of un outdoor area. The drawing is then discussed and considered as a means of understanding critical elements of the experience of life space. The material derived is discussed from the eerspectives of family systems, psychodynamic, and abuse treatment theories, with special reference to notions of family structure, boundary, the self, and memory. Emphasis is placed on the actual physical layout of the home, as well as the subjective experience of it. Applications of the drawing technique for exploring memories are illustrated. Case examples are presented from clinical trials with children and adults in residential treatment, inpatient, and outpatient settings.The Heller Financial Corporation generously supports the development of household and spatial drawings for treatment and prevention. A version of this paper was presented at the 43rd Annual Meeting of the American Association of Psychiatric Services for Children, New Orleans, February 26, 1992. The author wishes to thank Robert B. Bloom, Ph.D., Excutive Director of JCB, for supporting the development of ideas and techniques discribed in this paper.     

International migration and sustainable human development in eastern and southern Africa

International migration in eastern and southern Africa (ESA) is rarely addressed in population and development policies or regional organizations, and regional organizations must in the articulation of sustainable shared development identify the role of international migration. Poor quality data on international migration hampers analysis. Sustainable, shared, and human development within the region are subregional issues. Permanent migration is characterized among ESA countries as increasing demographic ethnic pluralism that may result in redrawing of territorial boundaries and further population movement. Portuguese and Arab settlement and integration in eastern areas resulted in coexistence, while European immigration to South Africa resulted in racial segregation. Modern colonial settlement and the aftermath of political conflict resulted in independent countries after the 1960s and outmigration of nonAfrican groups. Much of the labor migration in ESA is unskilled workers moving to South African mining regions. Labor migration to Zimbabwe and Zambia declined after the 1960s. The formation of the Common Market for ESA and the potential merger with the Preferential Trade Area and South African Development Community is a key approach to integration of migration into regional cooperation and shared development. Refugee movements create the most problems. Prior to 1992 ESA countries accounted for 83.4% of refugees, particularly in Mozambique, Ethiopia, and Somalia. Some countries blame poor economic performance on the deluge of refugees. Illegal migration is currently detected because of the required work permits, but the adoption of the Common Market would obscure this phenomenon. Human development is affected most by migrations related to drought, labor migration to strong economic areas, and return migration. The Inter-Governmental Authority on Drought and Development needs to become more active and establish better policies on nomadic and refugee movements and displaced populations. Movement of educated populations to countries lacking in trained and skilled human resources is a future challenge. Strategies of immigration should facilitate economic development.     

International migration: demographic and socioeconomic consequences in the United Kingdom and Europe

"This article evaluates the consequences of international migration since World War II, with particular reference to Great Britain. It emphasizes the substantial differences between the origins and responses to immigration in the United Kingdom and that of the rest of Western Europe." It is found that "people of non-European origin from Commonwealth countries have predominated in postwar immigration to the United Kingdom. That migration neutralized the previously dominant pattern of emigration and increased U.K. population by about 3 million people through immigration and higher fertility, with only slight effects upon the age distribution."     

Application of Markov chain Monte Carlo methods to modelling birth prevalence of Down syndrome

Data collected before the routine application of prenatal screening are of unique value in estimating the natural live-birth prevalence of Down syndrome. However, much of these data are from births from over 20 years ago and they are of uncertain quality. In particular, they are subject to varying degrees of underascertainment. Published approaches have used ad hoc corrections to deal with this problem or have been restricted to data sets in which ascertainment is assumed to be complete. In this paper we adopt a Bayesian approach to modelling ascertainment and live-birth prevalence. We consider three prior specifications concerning ascertainment and compare predicted maternal-age-specific prevalence under these three different prior specifications. The computations are carried out by using Markov chain Monte Carlo methods in which model parameters and missing data are sampled.     

The paradox of multiple elections

Assume that voters must choose between voting yes (Y) and voting no (N) on three propositions on a referendum. If the winning combination is NYY on the first, second, and third propositions, respectively, the paradox of multiple elections is that NYY can receive the fewest votes of the 2³ = 8 combinations. Several variants of this paradox are illustrated, and necessary and sufficient conditions for its occurrence, related to the “incoherence” of support, are given. The paradox is shown, via an isomorphism, to be a generalization of the well-known paradox of voting. One real-life example of the paradox involving voting on propositions in California, in which not a single voter voted on the winning side of all the propositions, is given. Several empirical examples of variants of the paradox that manifested themselves in federal elections – one of which led to divided government – and legislative votes in the US House of Representatives, are also analyzed. Possible normative implications of the paradox, such as allowing voters to vote directly for combinations using approval voting or the Borda count, are discussed. Received: 31 July 1996 / Accepted: 1 October 1996