Running toward the roar

How do you embrace paradox, changing and growing without losing your sense of who you are? We talked last time about the paradox of reaching for the new, without losing your ground in the old. Paradox is the place of insight. Accepting paradox, not as a momentary distraction but as a place to live, lies at the heart of dealing successfully with change. We can see this most clearly if we ask ourselves, "What business am I in? What am I about?" In health care, this did not used to be a meaningful question. Today, it is a critical one. But to really develop, we have to seek out the situations that are the most difficult for us, work them through, hang out with them long enough to begin to be at home in the paradoxical, ambiguous, and strange circumstance.     

Mixed estimation of old-age mortality

"Section 2 will first extend the method of mixed estimation to maximum likelihood estimation in general. Then, we will review generalized linear models with logistic and Poisson regressions as examples. In Section 3 we discuss different approaches for formulating the auxiliary information in practice. Section 4 first reviews the method of Coale and Kisker, provides empirical estimates for it, and then proceeds with the mixed estimation variant. In Section 5 we apply the methods to the estimation of mortality at ages 80+ in Finland in 1980-1993. We will first consider the evidence for mortality crossover between males and females....Then we will estimate life expectancies at age 100." (EXCERPT)     

Summing up. Recommendations and experiences for evaluation of community-level prevention programs

This article provides recommendations and observations about evaluation of a locally based prevention project to reduce problems at a total community or aggregate level. The shift from targeting specific individuals or subpopulations to the overall structure and environment of a community is most demanding. Evaluation tools and analysis techniques have lagged behind program development because community-level interventions are not linked to a specific target group who can be separately studied. Thus assumptions about using random assignment and/or comparison communities as means to control for confounding variables are weakened when the unit of analysis is the community itself and dependent measures are subject to trending and the effects of history.     

Pastoral care in Candyland. Maintaining power and life in a world of illness

Wrestling with ghosts and staging fatal accidents with Matchbox cars allow a critically ill six-year-old to come to terms with the fears prompted by his illness.     

Protecting hospital records from discovery

One of the more burdensome tasks confronting hospital administrators and defense counsel in hospital liability cases is attempting to protect sensitive or confidential information contained in hospital records. Plaintiffs' counsel continue to refine and broaden document requests as they become more sophisticated and experienced, learning about additional categories of documents that may be helpful to their cause. There are conditions that protect documents from discovery, but the rules of privilege are complicated and are frequently misunderstood.     

The private practitioner in hospital quality assurance

External forces continue to dictate the necessity of delivering high-quality health care along with methods of proving that the claimed quality is attained. Gone are the days when both the institution and its practitioners could answer quality questions simply by stating that they were delivering excellent health care to their patient population. The federal government, via the Health Care Financing Administration, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are mandating that institutions prove, without question, that they are delivering health care of the highest quality. The essential key to attaining these goals is cooperative private practitioners.     

Informed decision making: the new paradigm

Health care cannot survive in its present form. It is becoming unaffordable for a large share of the country's population. Its quality and effectiveness inexplicably vary between communities and across time. With all these problems, the process of health care can be understood. All that are needed are good, basic data; its access, management, and analysis; and then presentation of facts and observations. Together, these functions describe the translation of data into information--the field of medical informatics. Information about such management concerns as clinical efficiency (which largely is related to appropriateness and cost-effectiveness) and about the realities of day-to-day medical practice can be used to improve the value of health care. Informed decision making is based solely on confidence that, given the right information and understanding, we can all make the right decisions. The right decisions mean better patient acceptance and satisfaction, a sense of value enhancement by payers, and support of the Hippocratic tradition.