Hospital Performance, the Local Economy, and the Local Workforce: Findings from a US National Longitudinal Study

Blustein and colleagues examine the associations between changes in hospital performance and their local economic resources. Locationally disadvantaged hospitals perform poorly on key indicators, raising concerns that pay-for-performance models may not reduce inequality

Psychologists’ dilemmas in career counselling practice

In this study, we explored main dilemmas psychologists face in career counselling in two main professional settings: employment and education. Participants included 24 experienced Portuguese psychologists, working in employment (n = 14) and educational (n = 10) settings. We used consensual qualitative research to conduct and analyse semi-structured interviews. Results revealed dilemmas’ in five domains: neutrality, assessment, dual loyalty, role boundaries, and confidentiality, with the typical dilemma in the domain of neutrality. Differences between groups were found in the domains of dual loyalty and role boundaries.Dans cette étude, nous avons exploré les principaux dilemmes rencontrés par les psychologues dans le conseil en orientation dans deux milieux professionnels centraux: le placement et l’éducation. Parmi les participants figuraient 24 psychologues portugais expérimentés travaillant dans des contextes de placement (n = 14) et d’éducation (n = 10). Nous avons utilisé la recherche qualitative consensuelle pour mener et analyser les entretiens semi-structurés. Les re´sultats ont révé lé des dilemmes dans cinq domaines: la neutralité, l’évaluation, la double loyauté, les limites du rôle, et la confidentialité, avec le dilemme typique dans le domaine de la neutralité. Les différences entre les groupes ont été identifiees dans les domaines de la double loyauté et les limites du rôle.In dieser Studie untersuchten wir die hauptsä chlichen Dilemmata, mit denen Psychologen in der Berufsberatung in zwei wesentlichen professionellen Einrichtungen konfrontiert sind: Beruf und Bildung. Zu den Teilnehmern geho ¨rten 24 erfahrene portugiesische Psychologen, die in Einrichtungen von Beruf (n = 14) und Bildung (n = 10) arbeiteten. Wir verwendeten einvernehmliche qualitative Forschung um semi-strukturierte Interviews durchzufu¨hren und zu analysieren. Die Ergebnisse zeigten Dilemmata in fünf Bereichen: Neutralität, Beurteilung, doppelte Loyalität, Rollengrenzen und Vertraulichkeit, mit dem typischen Dilemma in der Domäne der Neutralität. Unterschiede zwischen den Gruppen wurden in den Bereichen der doppelten Loyalität und Rollengrenzen gefunden

Outcomes research in the development and evaluation of practice guidelines

BACKGROUND: Practice guidelines have been developed in response to the observation that variations exist in clinical medicine that are not related to variations in the clinical presentation and severity of the disease. Despite their widespread use, however, practice guideline evaluation lacks a rigorous scientific methodology to support its development and application. DISCUSSION: Firstly, we review the major epidemiological foundations of practice guideline development. Secondly, we propose a chronic disease epidemiological model in which practice patterns are viewed as the exposure and outcomes of interest such as quality or cost are viewed as the disease. Sources of selection, information, confounding and temporal trend bias are identified and discussed. SUMMARY: The proposed methodological framework for outcomes research to evaluate practice guidelines reflects the selection, information and confounding biases inherent in its observational nature which must be accounted for in both the design and the analysis phases of any outcomes research study

The Association of Ambulatory Care with Breast Cancer Stage at Diagnosis Among Medicare Beneficiaries

OBJECTIVE: Although nearly all elderly Americans are insured through Medicare, there is substantial variation in their use of services, which may influence detection of serious illnesses. We examined outpatient care in the 2 years before breast cancer diagnosis to identify women at high risk for limited care and assess the relationship of the physicians seen and number of visits with stage at diagnosis. DESIGN: Retrospective cohort study using cancer registry and Medicare claims data. PATIENTS: Population-based sample of 11,291 women aged ≥67 diagnosed with breast cancer during 1995 to 1996. MEASUREMENTS AND MAIN RESULTS: Ten percent of women had no visits or saw only physicians other than primary care physicians or medical specialists in the 2 years before diagnosis. Such women were more often unmarried, living in urban areas or areas with low median incomes (all P≥.01). Overall, 11.2% were diagnosed with advanced (stage III/IV) cancer. The adjusted rate was highest among women with no visits (36.2%) or with visits to physicians other than primary care physicians or medical specialists (15.3%) compared to women with visits to either a primary care physician (8.6%) or medical specialist (9.4%) or both (7.8%) (P <.001). The rate of advanced cancer also decreased with increasing number of visits (P <.001). CONCLUSIONS: Even within this insured population, many elderly women had limited or no outpatient care in the 2 years before breast cancer diagnosis, and these women had a markedly increased risk of advanced-stage diagnosis. These women, many of whom were unmarried and living in poor and urban areas, may benefit from targeted outreach or coverage for preventive care visits