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Quality issues strike the classical conflict in a democratic health-care deliverysystem of different interests among the politicians, the medical profession andpublic officials. This cannot be studied as a cut-off whiz. Quality registers havedeveloped over the past 40 years. Therefore, this paper puts the innovation ofquality registers in an institutional perspective. Two things are essential in thispaper. First, this paper reviews the emergence of quality registers in Swedish healthcare as an effect of institutional arrangements. Second, it analyses the interactionof diverse factors in different institutional settings and logics. The relevant data forthe study was collected from official/unofficial policy documents and key actorinterviews.The empirical findings show that three different waves of development can betraced in history that has highly affected the development of quality registers. Italso shows that medical quality is framed and determined by physicians in line withprofessional knowledge and by the primary institutional logic of quality in medicalcare. However, organisational quality in health care is framed by the logic ofpublic equity of access based on a third party payer and the logic of managerialcontrol. These two paths of quality developments are now federating in aninstitutional logic of transparency. The contribution of this paper is importantbecause it produces insights in different institutional logics, which frames the riseof the two quality paths and the problems they have to face in order to merge. It also enhances the existing knowledge that institutions matter.

Quality issues strike the classical conflict in a democratic health-care deliverysystem of different interests among the politicians, the medical profession andpublic officials. This cannot be studied as a cut-off whiz. Quality registers havedeveloped over the past 40 years. Therefore, this paper puts the innovation ofquality registers in an institutional perspective. Two things are essential in thispaper. First, this paper reviews the emergence of quality registers in Swedish healthcare as an effect of institutional arrangements. Second, it analyses the interactionof diverse factors in different institutional settings and logics. The relevant data forthe study was collected from official/unofficial policy documents and key actorinterviews.The empirical findings show that three different waves of development can betraced in history that has highly affected the development of quality registers. Italso shows that medical quality is framed and determined by physicians in line withprofessional knowledge and by the primary institutional logic of quality in medicalcare. However, organisational quality in health care is framed by the logic ofpublic equity of access based on a third party payer and the logic of managerialcontrol. These two paths of quality developments are now federating in aninstitutional logic of transparency. The contribution of this paper is importantbecause it produces insights in different institutional logics, which frames the riseof the two quality paths and the problems they have to face in order to merge. It also enhances the existing knowledge that institutions matter.

• Summary: We assessed patient and provider barriers and facilitators to sustainability of a collaborative depression care model for depression treatment in predominantly Hispanic diabetes patients in safety net care clinics. • Findings: Semi-structured interviews and focus groups were conducted with patients and providers at two community clinics participating in a randomized controlled effectiveness trial of the Multi-faceted Depression and Diabetes Program (MDDP), a socioculturally adapted collaborative care model. Analysis identified eight themes grouped into three categories: barriers, facilitators, and recommendations for program sustainability. Barriers included patient concerns about use of medication and provider concerns about use of psychotherapy, increased workload for clinic staff, delay in receiving outcomes data, and lack of resources to sustain the program. Facilitators included patient benefits such as improved clinical outcomes, quality of care received, access, and satisfaction; provider benefits such as increased awareness and reduced anxiety; and clinic benefits in the form of reduced costs of care. Recommendations included changes in communication patterns among providers, specific changes in procedures, changes in resources, and changes in clinic organizational culture. • Applications: Sustainable adoption of collaborative depression care for underserved populations in safety net care systems by organizational decision-makers and providers requires: stable funding and qualified staff; technologies to facilitate provider access to easily applied treatment guidelines, information exchange between primary care physicians and depression care providers, and routine monitoring of patient depression symptoms and treatment adherence and satisfaction; and treatment consistent with patient preferences.

AbstractThe life expectancy of adults with Down syndrome has increased dramatically over the last 30 years, leading to increasing numbers of adults with Down syndrome now living into middle and old age. Early‐onset dementia of the Alzheimer type is highly prevalent in adults with Down syndrome in the sixth decade, and this has overshadowed other important conditions related to aging among adults with Down syndrome. The authors' aim was to update and summarize current knowledge on these conditions, and examine causes of morbidity and mortality in older people with Down syndrome by conducting a systematic review of the published literature for the period: 1993–2008. They reviewed English‐language literature drawn from searches in the electronic databases Medline, CINAHL, and PsycINFO, as well as supplementary historical papers. The authors conclude that functional decline in older adults with Down syndrome cannot be assumed to be due only to dementia of the Alzheimer type (which is not inevitable in all adults with Down syndrome). Functional decline may be the result from a range of disorders, especially sensory and musculoskeletal impairments. Given the high rates of early‐onset age‐related disorders among adults with Down syndrome, programmatic screening, monitoring, and preventive interventions are required to limit secondary disabilities and premature mortality. With respect to assessment and treatment, in the absence of specialist disability physicians, geriatricians have a role to play.

The past two decades saw tremendous achievements in blood safety, which are due to the commitment of blood establishments and industry, progress in technology such as the improvement of serological and NAT screening tests, and stringent regulatory control. Milestones in the legislation were the inclusion of plasma derivatives in the pharmaceutical legislation of the European Community (EC) in the year 1989 and special laws for the blood sector in EC and in member states, such as the Transfusionsgesetz (Transfusion Law) in Germany. The legal frame has to be supplemented by scientific and technical guidance, which is provided on the European level by the European Directorate for the Quality of Medicines and Health Care and by the European Medicines Agency. In the member states, guidelines taking into account the national peculiarities can be elaborated, such as the German hemotherapy guidelines issued by the German Medical Association (Bundesärztekammer) in agreement with the Paul-Ehrlich-Institut. The regulatory control of screening tests, and the introduction of NAT testing lead to a remarkably high degree of safety concerning the most relevant viruses HIV, HBV and HCV. Issues needing further attention are bacterial contamination and transfusion-associated acute lung injury (TRALI). Measures aiming at minimizing risks have to be balanced against their impact on supply. In order to ensure the assured supply with safe blood products, sustained efforts and research are needed as well as a continuous dialogue among blood services, industry, physicians, patients and regulatory authorities.

Although Cambodia's total fertility rate is declining, limited access to and use of contraceptives has meant that some women rely upon induced abortion, legal since 1997, to achieve their fertility intentions. This study identifies factors that facilitate acceptance of postabortion contraception among women using Cambodia's public health facilities. Data were collected in all of Cambodia's hospitals with obstetric and delivery services (n = 71) and a representative sample of 115 of its 887 health‐care centers, and from women seeking induced abortion or with abortion complications who presented to selected facilities during a three‐week period (n = 933). Weighted data from 316 women who reported not wanting to become pregnant within the next few months and who presented to facilities that provide postabortion contraceptives were analyzed for bivariate and multivariate associations. Approximately 42 percent of women accepted contraceptives at the conclusion of care. After controlling for individual and facility characteristics, women who presented at facilities where a nurse/midwife managed abortion services, where contraceptives and abortions were provided in the same room, and where a larger range of methods were offered had significantly higher odds of contraceptive acceptance following abortion care. Improving contraceptive counseling and training for midwives and physicians, increasing contraceptive choices, and promoting access to contraceptives on site may reduce Cambodian women's risk of unwanted pregnancy and, potentially, unsafe abortion.

This study is the first to estimate the price elasticities of demand for both medical rehabilitation programs and treatment at health spas. In Germany, the Statutory Health Insurance (SHI) covers both forms of therapy if administered in authorized medical facilities on referral from a physician. While health resort stays are prescribed to recover from general symptoms of poor health and are preventive in character, medical rehabilitation implies recovering from a specific illness or accident. From 1997 onwards, the German government more than doubled the copayments for both types of health care services from DM 12 (e6.14) to DM 25 (e12.78) per day for those insured under the SHI. Using longitudinal microdata from the German Socio-Economic Panel Study (SOEP), this exogenous price variation allows us to study the causal effects on demand, since we have a sound control group available. The data suggest that pull-forward effects in 1996 accounted for up to one-fifth of the subsequent decrease in demand. Taking this anticipation effect into account, we show that the reform induced a decrease in total demand of about 20 percent. We estimate the price elasticity for rehabilitation programs that aim at preventing work incapacity to be about -0.15, whereas the elasticity for rehabilitation programs for recovery from work accidents lies around -0.30. In contrast, the price elasticity for treatment at health spas is elastic and lies between -1 and -2.5.

This study is the first to estimate the price elasticities of demand for both medical rehabilitation programs and treatment at health spas. In Germany, the Statutory Health Insurance (SHI) covers both forms of therapy if administered in authorized medical facilities on referral from a physician. While health resort stays are prescribed to recover from general symptoms of poor health and are preventive in character, medical rehabilitation implies recovering from a specific illness or accident. From 1997 onwards, the German government more than doubled the copayments for both types of health care services from DM 12 (e6.14) to DM 25 (e12.78) per day for those insured under the SHI. Using longitudinal microdata from the German Socio-Economic Panel Study (SOEP), this exogenous price variation allows us to study the causal effects on demand, since we have a sound control group available. The data suggest that pull-forward effects in 1996 accounted for up to one-fifth of the subsequent decrease in demand. Taking this anticipation effect into account, we show that the reform induced a decrease in total demand of about 20 percent. We estimate the price elasticity for rehabilitation programs that aim at preventing work incapacity to be about -0.15, whereas the elasticity for rehabilitation programs for recovery from work accidents lies around -0.30. In contrast, the price elasticity for treatment at health spas is elastic and lies between -1 and -2.5.

Die Hitler-Jugend war eine obligatorische oder quasi-obligatorische Massenorganisation, die sich bis zum Untergang des Dritten Reichs nie von pädagogischer und ideologischer Führung und Kontrolle befreien und in diesem Sinne auch nie zu einer autonomen jugendkulturellen Bewegung wurde. Im Vordergrund der staatlichen Beschäftigung mit der Jugend stand ihr Nutzen für die Nation, der sich vorrangig in optimierter physischer Leistungsfähigkeit und "wertvollen" Erbanlagen ausdrückte und mit einer Utopie vom perfekten Körper und einer hochgezüchteten Herrenrasse einherging. Die "Gesundheitsführung" der Jugend galt im NS-Staat als politisch-ideologische Aufgabe und war in ein System "totaler Erziehung" eingeordnet, in dem Jugendärzte als "Kameraden der Jugend" von medizinischer Seite her in die Entwicklung und Ausbildung der gesunden Jugend eingreifen sollten. Diese Programmatik und die konkreten Ausprägungen der völkischen Utopie vom "Neuen Menschen" werden am Beispiel des Gesundheitsdienstes der Hitler-Jugend untersucht und beschrieben. ; The Hitler Youth was a mandatory or quasi-mandatory mass organization that stood under pedagogical and ideological control all though the Third Reich and thus never became an autonomous cultural youth movement. The main goal of government and Nazi Party regarding the education and development of adolescents was to optimize the physical performance and "valuable" hereditary disposition. This concept was based on the vision of the perfect body and the creation of the master race. The health leadership ("Gesundheitsführung") of adolescents in Nazi Germany was regarded as a political and ideological task. It was integrated in a system of "total education" in which "Jugendärzte" (specialized physicians for adolescents) who saw themselves as comrades of youth intervened in the development and education of the healthy adolescents. The steps towards the racial utopia of shaping the master race will be specified by taking a close look at the activities of the Medical Service of the Hitler ...

William W BostockSchool of Government, University of Tasmania, Hobart, Tasmania, AustraliaAbstract: Psychiatrists have long had involvement with the political process, both individually and as a profession. They have made valuable contributions to debate over such issues as war, conflict, terrorism, torture, human rights abuse, drug abuse, suicide and other public health issues. However, they have also been complicit in some gross atrocities. Over several years there has been debate over the Australian Government's treatment of asylum seekers, and the Royal Australian and New Zealand College of Psychiatrists took the unusual step of publicly criticizing the Australian Government's policy on grounds of its toxicity leading to a diagnosis of collective depression syndrome, particularly among child detainees, but also adult detainees. The official Ministerial response was to deny that collective depression exists and to assert that the concept is meaningless. Can this intervention by psychiatrists be interpreted as a product of earlier political behaviors by psychiatrists? The willingness of psychiatrists to cooperate with other professions, notably psychologists, pediatricians, physicians and lawyers, is noted, as is presence of minority voices within the Australian psychiatric profession. The significance of the debate over the mental condition of asylum-seeking detainees is that its outcome has implications for how Australia sees itself and is seen by the rest of the world, that is, its national identity.Keywords: collective depression syndrome, psychiatric profession, political intervention, asylum seeker, Australian national identity

This study aimed at investigating the use of psychosocial interventions and psychotropic co-medication among stimulant-treated children with attention-deficit hyperactivity disorder (ADHD) in relation to the presence of psychiatric co-morbidity. Stimulant users younger than 16 years were identified in 115 pharmacies and a questionnaire was sent to their stimulant prescribing physician. Of 773 questionnaires sent out, 556 were returned and were suitable for analysis (72%). The results are based on 510 questionnaires concerning stimulant-treated children for whom a diagnosis of ADHD was reported. Of the 510 children diagnosed with ADHD, 31% had also received one or more other psychiatric diagnoses, mainly pervasive developmental disorder or oppositional defiant disorder/conduct disorder. We found an association between the presence of co-morbidity and the use of psychosocial interventions for the child (P < 0.001) and the parents (P < 0.001). In the ADHD-only group, 26% did not receive any form of additional interventions, while psychosocial interventions varied from 8 to 18% in children with ADHD and psychiatric co-morbidity. The presence of diagnostic co-morbidity was also associated with the use of psychotropic co-medication (overall, P = 0.012) and antipsychotics (P < 0.001). Stimulant-treated youths with ADHD and psychiatric co-morbidity received more psychosocial interventions and psychotropic co-medication than children with ADHD-only. The type of psychosocial interventions and psychotropic co-medication received by the children and their parents, depended on the specific co-morbid psychiatric disorder being present.

<i>Objective:</i> To describe the psychological reaction to information about diagnostic genetic testing for α-1 antitrypsin deficiency (Alpha-1) and cystic fibrosis (CF) in chronic obstructive pulmonary disease and/or bronchiectasis patients who were tested but did not know the results. <i>Methods:</i> One hundred and three adults took the State-Trait Anxiety Inventory before and after a standardized educational intervention and responded to a questionnaire. <i>Results:</i>Information about the limitations, risks and benefits of Alpha-1 and CF testing did not raise mean anxiety levels. Mean anxiety was slightly lower after the educational intervention than at baseline (mean pretest score 35.0, posttest score 33.7; p < 0.05). Participants whose physician preinformed them of genetic testing had slightly higher mean anxiety than other participants, both before and after the intervention, but scores were comparable to those in a normative sample of general medical and surgical patients. <i>Conclusions:</i> Disclosure of information regarding Alpha-1 and CF testing appears to be potentially acceptable to patients and unlikely to prevent clinicians from conducting useful diagnostic procedures. This study is a step in alleviating concerns about raising issues related to genetic testing for Alpha-1 and CF in chronic obstructive pulmonary disease patients during the informed consent process.

Das Forschungsprojekt WAMP (Wandel von Medizin und Pflege im DRG-System) beschäftigt sich schon seit der Zeit vor der Einführung der Diagnosis Related Groups (DRGs) mit den (möglichen) Folgen der DRGs auf die Arbeitsbedingungen und die Versorgungsqualität im Krankenhaus. Die Grundannahme ist, dass die DRGs neben anderen ordnungspolitischen Faktoren dazu beitragen, die Strukturen im Krankenhaus zu verändern. Veränderte Strukturen im Krankenhaus haben wiederum Auswirkungen auf die Arbeitsorganisation, auf die Arbeitsprozesse, die Arbeitsbelastungen und somit indirekt auch auf die Versorgungsqualität. Die vorliegende Studie zeigt aus Sicht hessischer Krankenhausärzte den Wandel der Strukturen im Krankenhaus als auch der Arbeitsbedingungen, des beruflichen Selbstbildes und der Versorgungsqualität. Aus zwei in weiten Teilen identischen Befragungen Anfang 2004 und Ende 2005 lassen sich erste Tendenzen erkennen. In Bezug auf die Arbeitsbedingungen, das berufliche Selbstbild und die Versorgungsqualität besteht ein direkter Zusammenhang mit einer Ressourcenverknappung, die durch anhaltende Budgetierung und das neue Entgeltsystem ausgelöst wurde. ; Since the time before the implementation of the diagnosis related groups (DRGs) the research project WAMP (Changes in medicine and nursing in the DRG-system) deals with the consequences of the DRGs on working conditions and the quality of care in hospital. The project starts with the assumption, that the DRGs effects the structures in hospital care. Changes in these structures will cause changes in process organisation, working load and finally mediately on the quality of care. Based on two nearly identical investigation this study shows from the point of view of Hessian physicians the changes in process organisation, self definition and quality of care. The investigations where carried out in February 2004 and November 2005. First results show a coherence between the restricted budget and the DRGs on the one hand and the process organisation, self definition and the quality of care on the other hand.

Testimony issued by the Government Accountability Office with an abstract that begins "Millions of drivers hold commercial driver licenses (CDL), allowing them to operate commercial vehicles. The Department of Transportation (DOT) established regulations requiring medical examiners to certify that these drivers are medically fit to operate their vehicles and provides oversight of their implementation. Little is known on the extent to which individuals with serious medical conditions hold CDLs. Because the effectiveness of the medical certification process is not known, this testimony, and the accompanying report (GAO-08-826) that GAO is releasing today focuses on (1) GAO's analyses of the magnitude of commercial drivers with serious medical conditions, and (2) examples of cases where careful medical examinations did not occur on commercial drivers with serious medical conditions. To examine the extent individuals holding CDLs have significant disabilities, GAO identified those who were in both DOT's CDL database and selected disability databases of Social Security Administration, Office of Personnel Management, and Departments of Veterans Affairs and Labor and have been identified as 100 percent disabled according to the program's criteria. GAO obtained current CDL data from 12 selected states. To provide case studies, GAO focused on 4 states--Florida, Maryland, Minnesota, and Virginia. For 15 drivers identified from data mining, GAO interviewed, as appropriate, the driver, the driver's employer and the driver's physician."

Considerable literature exists on the benefits of breast feeding on the health and survival of infants and young children, but there is less on the effects on later life outcomes. One such measure of health and well-being that has received attention in the historical literature is terminal adult stature. Information on height is rather widely available; however, it is much more difficult to obtain data on breast feeding. One country that does have such information is Imperial Germany (1871–1919). A number of physicians and local health officials collected information on the incidence and duration of breast feeding early in the 20th century, particularly because of concern about the unusually high infant mortality rates in parts of Germany. Hallie Kintner has surveyed the published results of these studies. The information on the prevalence of breast feeding for the period 1903/10 has been inputed into a database of demographic and economic variables for the counties (Regierungsbezirke) of Germany (1850–1939) There are also published data on heights of military recruits from the Imperial German military forces in 1906. These can be linked to areas in the database and related to breast feeding practices and infant mortality both contemporaneously and approximately 20 years previous to 1906. Results indicate a significant effect of infant feeding practices on later life outcomes operating through infant health conditions, proxied by the infant mortality rate.