Health Systems Research - Böcker

It is not easy to summarize the studies that have dealt with the health effects of un­ employment on the unemployed. The main problem impeding a comparison of their results is the diversity of theoretical constructs associated with physical and especially mental health and, above all, an apparently inexhaustible variety of op­ erationalizations of these constructs. It is significant that the six conclusions drawn from the present state of unemployment research by the organizers of a re­ cent conference on the individual and social consequences of unemployment in­ cluded the following request: "In view of the relevant constructs, it seems to be most urgent to find or to develop operationalizations which can be agreed upon, in order to guarantee comparability of research results" (Kieselbach and Wacker 1985, p. XX; my translation). Nevertheless, the results of these studies allow the statement that a negative in­ fluence of job loss on psychological well-being can be regarded as a validated finding. The influence on physical health, however, must be assessed very careful­ ly and in a differentiated manner. The few investigations dealing with this ques­ tion arrive at different conclusions; moreover, possibly relieving effects of unem­ ployment on health come into sight.

Technological development has created major possibilities for the treatment of disease and for the disabled. The cost of new technologies has added considerably to health care cost intlation, which still exceeds the growth rates of most national economies. The share of national resources devoted to health care is still rising, although at a lesser pace than in the seventies. -Therefore, the use of medical technology confronts us with some of the major dilemmas in society today. The routine and intensive use of technology has transformed the most basic interpersonal and social features of medicine. It has altered the means through which patient and doctor communicate about illness as well as the content of this communication, changed the doctor's relationship to medical colleagues by increasing his dependence on them, altered the place and form of practice by creating advantages for the centralization of medical care in complex organizations, and created for society new responsibilities and powers to influence the context and scope of medical practice.

A health policy for the future is the topic of discussion in this book. International scientists discuss central questions corresponding to the targets set by the World Health Organization (WHO). In a unique meeting, social political proposals and recommendations are presented for a regional health care system that includes public involvement. Separate sections of the book treat the primary health care system in relation to public involvement, family medicine, epidemiology, health economics, and institutional requirements.

Since the early 1970s, delivery of care to people who are consid- ered to suffer from chronic psychotic disturbances has been at a crossroads. In 1983, the European Regional Office of the World Health Organization (WHO), within its health economics pro- gramme, encouraged international research on the economic impli- cations of alternative strategies of care for those patients. Origi- nally, it was intended to compare at least two or more strategies of managing chronic psychotics, especially strategies which place dif- ferent emphasis on inpatient and outpatient care.Instead of designing a fully coordinated, multinational, multi- centre study based on a mutually agreed on study protocol, we de- cided on the following: - To meet with researchers interested in the social, psychological, and economic features of health care for chronic psychotic pa- tients - To stimulate ongoing research projects or to initiate new ones - To discuss quite different approaches from international and - terdisciplinary points of view - To review and revise the diversified end products of such an open research process For this purpose, we outlined a broad range of topics which could be included in the study: - Methodological problems of evaluation in this field - Social and economic implications of psychiatric deinstitutiona- zation - Scenarios of various degrees of deinstitutionalization - Assessment of (hospital) costs of the treatment for chronic sc- zophrenic and other psychotic patients - Public and private costs of the main treatment strategies - Time-expenditure analyses of chronic psychotic patients

From the early days of its recognized occurrence, AIDS has been per­ ceived as posing tremendous threats, burdens and challenges to human beings. Individuals, societies and, in a global point of view, mankind are affected by the effects of the HN infection, the nature and extent of which is still unclear in many ways. In the beginning only biomedical and epidemiological analyses of the problem were the top research priori­ ties, the former laden with great hopes that it may soon be possible to stop the spread of the disease and to overcome its physical impact. Yet it soon became clear that AIDS would be something to be reckoned and coped with on a long-term basis, making a thorough investigation of its impact absolutely mandatory. AIDS has serious economic consequences. Taken seriously, they can­ not be confined to predictions of costs intended to support the AIDS issue in the struggle for resources. Besides cost calculations - a method­ ologically tricky and wide-ranging topic in itself -and their application to cost-effectiveness and other analyses, economic issues include identify­ ing and assessing patterns of care, analyzing problems of financing, exploring impacts on markets other than health care, and modelling scenarios for future developments and strategies. At present, the eco­ nomic aspects of AIDS still constitute a very recent topic in European health economics and health systems research. Many projects are just about to start, and there must be a better exchange of information between research groups.

R. Leidl, P. Potthoff, and D. Schwefel Health is a most vital resource represented in the degree of our well-being and our ability to conduct active and satisfactory lives. Acute and chronic illnesses diminish such well-being and abilities and may require resources for medical or nursing care. The improvement in health status, a major objective of health policy, requires the measurement of the severity of diseases and their consequences as essential elements of information. In application, the measurement approaches are gaining in relevance as they become more feasible and as more experience is gathered about their implementation and utilization. The feasibility of these new information tools is supported by developments in data processing technologies that permit broadly based empirical applications. Wider applications lead to improvements in the management use of this information. At the European level, better indicator systems of diseases and their various aspects are facing an increasing demand for patient-based health and health system comparisons and analyses. The measurement of health status and its implications can comprise a number of dimensions: various concepts of health and disease, types of diseases, methodological approaches of measurement, purposes of application and states of implementation.

Europe faces the challenge of how to apply information and communication technologies to health care. One problem is the widening gap between the expectations of citizens and the limited resources available to provide health services. It is here that advanced technology can serve as an effective tool to find innovative and more efficient ways of delivering health services. This book summarizes a study carried out by a team of consultants for the Directorate General XIII of the Commission of the European Communities. It analyzes the key factors governing the evolution of advanced information systems for health care and medicine in Europe and provides guidelines for placing current and future work within the framework of Community research and development programmes. This book of proceedings on medical informatics is intended for researchers, educators and health care service authorities.

A new approach to the issue of incentives in health policy analysis is offered in this book, which cover a range of studies and discusses both theoretical and practical aspects of the subject. The main topics are the consumer's behaviour in terms of diet, lifestyle and so on; the provider's activities in terms of professional practice and financial incentives; and other-discipline measures from outside the health care sector. A different approach to clinical freedom is also considered with regard to improving health services efficiency.

As the focus on pharmaceuticals has broadened from concern for their cost and effectiveness to their real and potential risks and benefits, a critical question has been raised: whose responsibility is it to improve drug safety? In April 1990, this question became the theme for a conference at Wolfsberg, Switzerland, near the shores of Lake Constance. Called an "international dialogue conference" by its organizers, the meeting brought together leaders from the pharmaceutical industry, regulatory authorities, academia, medicine, consumer organizations and the media. Opening addresses were given by representatives of the Council for International Organizations of Medical Sciences (CIOMS), the International Federation of Pharmaceutical Manufacturers Associations (IFPMA), the Swiss International Pharmaceutical Agency, and the RAD-AR Consortium. This book documents the papers presented and discussions held at this conference, which took the topic of risks and benefits of drug therapy one step further to responsibility. It includes a rich menu of issues for those who care about the evaluation of drug therapy, the ethics behind it, the expectations of the patient, and the role of traditional and nontraditional drug safety communica­ tions. The ideas expressed here come from different parts of the world but relate to common drug safety problems, observations, and scientific assessments; they provide insights into innovative approaches, cautious changes, and desired actions. The papers in this volume are broadly divided into conceptual perspectives (ethics, how the knowledge about drug risks and benefits is generated and appraised, the expectations in drug safety) and operational perspectives (communication, discussion, and action).

Modern drugs are invented according to medical needs, making use of the latest innovations in technology. They are sophisticated, efficacious, and costly, but are they effective? Are they superior to existing - and cheaper - alternatives, and is this superiority reflected in increased cost-effectiveness? Are they socially more beneficial? These questions, and those related to the intriguing search for better quality of life, are addressed in this book by experts from the fields of medicine, epidemiology, economics, sociology and the pharmaceutical industry. The book describes the environmental situation in the United States and Europe in which pharmaceutical development takes place; it also explores the grounds for agreement as well as disagreement between the social and the economic evaluations of progress. It tackles the problem of outcome measurements, patients' behavior, quality of life, and individual value judgments and describes methodological boundaries in the socioeconomic evaluation of drugs.

In the past two decades public debate about the risks, benefits, and safety associated with drugs has intensified. Public disputes over risks are brought to court when individuals seek compensation for health problems attributed to a pharmaceutical product. The issue reaches legislatures and regulatory agencies when consumer advocates seek to influence the standards of drug usage. Front-page news tends to focus on accidents or other risk events with drugs. Drug risk and drug safety have become an important political issue. Drug regulat­ ory agencies have been instituted, and their responsibility has increased. The approval to market a drug is dependent on a set of sophisticated studies executed according to strict protocols and scientifically defined criteria. Drug surveillance activities have gained recognition, and reporting systems to identify drug safety problems have been strengthened. The understanding and management of drug safety is, nonetheless, beset by doubts, disagreements, and disputes. Conflict occurs over the significance of risk, the adequacy of evidence, the methodologies used to evaluate and measure risk, the standards that guide regulation, and the optimal means of communicating risk information to the public.