The Irish National Health Service is a combination of state supported and private practice service . Approximately 31% (1.24 million) of the Irish population are eligible for General Medical Services (GMS) scheme which supplies all medicines without any cost to socially disadvantaged persons and their dependants, based upon a means test. All persons ≥70 years of age are also entitled to GMS membership. The GMS population received about 70% of all medications prescribed in general practices at a cost of 340 million Euros in 2000. Community pharmacies providing services for GMS patients use computer software for dispensing and processing the claims information to the GMS Payments Board. The Payments Board then processes the pharmacist’s claims and keeps a record of them. The GMS Payments Board data records contains information such as: claim number-, patient GMS number-, prescribing doctor-, pharmacy number, drug name, drug code, ATC level, pharmaceutical form, strength, Defined Daily Doses (DDD), price, month and year. The drugs are classified according to the World Health Organizations (WHO) Anatomical Therapeutic Chemical (ATC) classification system. The quantitative unit Defined Daily Doses (DDDs) is the assumed average maintenance dose per day for a drug used for its main indication in adults . For each drug a theoretical daily dose (DDD) has been defined based on the recommended daily use by an adult for the drugs mains indication. The DDDs for the drugs are updated by the WHO Collaborating Centre for Drug Statistics methodology in Oslo, Norway.
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Copyright © 2011 Conor Teljeur et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The general medical services (GMS) scheme provides care free at the point of use for the 30% most economically deprived section of the population and the elderly. Almost all people of over-70-year olds are eligible for the GMS scheme potentially directing resources away from those most in need. The aim of this study is to analyse the relationship between practice GMS income and deprivation amongst Dublin-based general practitioners (GPs). The practice GMS income in Dublin was analysed in relation to practice characteristics including the number of GPs, catchment area population, proportion of over-70-year olds in the catchment area, catchment deprivation, number of GMS GPs within 2 km, and average GMS practice income within 2 km. Practice GMS income was highest in deprived areas but is also a valuable source of income in the least deprived areas. The capitation rate for over-70-year olds provides an incentive for GPs to locate in aﬄuent areas and potentially directs resources away from those in greater need.
The most significant contributor to pharmaceutical expenditure in Ireland is the GMS (medical card) scheme. This is a community drug scheme, whereby drugs, medicines and appliances supplied under the Scheme are provided through retail pharmacies. All GMS claims are processed and paid by the Primary Care Reimbursement Service (PCRS). The scheme is means tested and eligibility is based on income. Persons who are affected by certain medical conditions are also eligible for the scheme. Those who are unable without undue hardship to arrange general practitioner medical and surgical services for themselves and their depen- dants are eligible to receive free general medical service under the scheme and are issued with a medical card. The scheme is financed by the state with a co-payment from each eligible person introduced in 2010. Since October 2010, each person on the scheme has in- curred a €0.50 charge for every prescription item dis- pensed. This was subsequently increased to €1.50 in 2013 and is currently €2.50 per prescription item up to a maximum of €25 per family per month. Between July 2001 and December 2008, all persons over 70 were granted a free medical card. Due to the economic crisis, eligibility criteria were introduced on the 1 st of January 2009 so that all persons ≥70 were means tested.
From July 1997 till date, he has been working in Nairobi, Kenya with the Office of the Auditor-General as an assistant manager in charge of ICT Audit. He has four years part-time teaching experience in IT with Kenya Methodist University. Previously, he worked with Teachers Service Commission of Kenya and Group 4 Security, Kenya. Some of his publications are 1) Kamenyi, D. M., et al., Authenticated privacy preserving for continuous query in location based services. Journal of Computational Information Systems, 9(24), 9857-9864; 2) Kamenyi, D. M., et al. Preserving users’ privacy for continuous query services in road networks. Proceedings of 2013 6th International Conference on Information Management, Innovation Management and Industrial Engineering: Vol. 1 (pp. 352-355); 3) Kamenyi, D. M., et al. Optimizing placement of mix zones to preserve users’ privacy for continuous query services in road networks. Proceedings of 2013 9th International Conference on Advanced Data Mining and Applications (pp. 323-335).
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China has the second largest burden of tuberculosis (TB) in the world , and the “directly observed treatment short course” (DOTS) has been implemented by China’s National TB Program to combat this problem. One smear microscopy and one radiography at first visit, and drugs (6 months for new patients, 8 months if previously treated) are provided free of charge. Despite this, TB pa- tients frequently encounter high costs, often through add- itional medicines, X-rays and laboratory services, during the course of their treatment [2–4]. Within the current TB control program, two main approaches have been employed in China: the TB dispensary approach and the integrated approach . In the TB dispensary approach, TB dispensaries [usually departments of the Center for Diseases Control (CDC)] are in charge of TB case detec- tion, diagnosis, treatment, and case management. TB sus- pects and patients should be reported and referred to TB dispensaries to confirm diagnoses and for treatment by health workers in general hospitals. Only severe or com- plicated TB cases are further treated in general hospitals. Since 2000, TB prevention and treatment services have transformed from TB dispensaries to designated hospitals in what is called the integrated approach. This design al- lows TB dispensaries to provide public health care and general hospitals to offer integrated care to TB patients without referral. Other hospitals, including township hos- pitals, are responsible for referring suspects and patients to the designated hospitals. The integrated model has been considered the better policy option for future TB health reform in China . Prior studies have shown that TB poses a heavy financial burden on patients, especially on those in rural areas . A systematic review conducted in low- and middle-income countries has shown that cost as a percentage of income was particularly high among poor people . With the considerable strain that TB places on its population, protecting TB patients from fi- nancial risk is a priority for Chinese policymakers.
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that the equity in utilization of outpatient health services was relatively worse than that for the in-patient services. The full implementation of NCMS has improved the utilization of health services, but has also caused a con- comitant increase in the health expenditure. Furthermore, some participants did not utilize health services due to the economic burden, which was not taken into account seriously for the present. The resilience of the low-income groups against economic risks of disease is less than that of the high-income groups, which not only relates to the greater need for health care in the former, but also to the lower amount of compensation that they are entitled to. Although NCMS reduces the incidence of CAH, the im- pact of NCMS, especially on the low-income groups has been limited (the percentage of lowest income group was 32.21%). The low-income group continues to experience the “high need, low utilization, high-burden, low-income” phenomenon. Our study suggests that the equity of health services has not significantly improved for rural residents.
This study was an applied retrospective cross- sectional study conducted in the second half of 2004. The understudy group consisted of patients diagnosed with asthma and COPD that had referred to Masih Daneshvari uni-speciality hospital (National Research Institute of Tuberculosis and Lung Diseases) and a governmental hospital namely the Shohada General Hospital. In this study, the total health services cost was estimated based on statistical techniques. Also, by designing special forms and tables, essential data in regard to costs of consumable materials, medication, fixed assets (office equipment, specialized equipment, and building), manpower, and overhead costs were recorded. After calculation, the total health services costs of asthmatic and COPD patients were compared. The number of admitted patients in Masih Daneshvari Hospital and Shohada General Hospital during the second half of 2004 was 85 and 60 cases respectively. Also the average total cost of patients was calculated.
Within this study the number of clients using smoking cessation services provided within dental and pharmacy settings forms only a small proportion of the total population using smoking cessation services in Bradford. Whilst this reflects the provision of these services by providers in Bradford, and in England more widely, caution should be exercised given the small numbers accessing these services compared to more traditional settings. The ratios of provision is in line with NICE guidance where the focus of smoking cessation services being commissioned within GMP services predominates 14 . The study is also limited in that data was collected in a single geographic location, Bradford. Bradford is typically classified within the 20 most deprived areas in England and has a more diverse ethnic population than the UK as a whole; thus the results may not be generalisable to other geographic areas. Across the country a standardised approach is taken to training ensuring consistency of training to ensure clinical and data management can be regulated as much as possible.
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In this study we were only able to evaluate the stu- dents ’ use of ML between campus and home. In subse- quent years of the medical degree, students will take their laptops into clinical settings across the region further testing the potential of ML and addressing a key driver for the program. In order to gain a broader per- spective of ML we intend to explore faculty responses to ML, their knowledge and perception of its’ potential and consider ways to incorporate ML with other educa- tional methods.
Diabetes self management training has traditionally been delivered in a didactic manner with emphasis on impart- ing knowledge. However this approach has been shown to be ineffective in changing the behaviour of individuals with type 2 diabetes and improving metabolic control . An alternative approach such as peer support may improve these outcomes. This approach is based on a social support theoretical framework rather than an edu- cational or psychological framework and the outcomes we have selected for the study reflect this underlying theoret- ical framework. The potential advantage of peer support is that it focuses on the impact of the illness on daily life rather than on medical information about illness. The group meeting components of the intervention in this study are designed to build on the lay element of peer sup- port through the encouragement of the sharing of experi- ences and exchanges between participants. Peer support is a complex intervention and a strength of this study has been the use of the MRC Framework for the evaluation of randomized controlled trial of complex interventions designed to improve health outcomes . Details of the initial phases of the framework leading to the finalisation of this protocol are presented elsewhere. (BMC Health Services Research, in press). The study is specifically based in the general practice setting and empowers and supports practice staff in the recruitment of participants and peer supporters and data collection. This approach embeds the study in the real world of primary care and will increase the generalisability of results. An additional strength of the study is its duration of two years, which allows us to test the sustainability of a peer support intervention in a clinical setting over time.
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It seems to me that one can distinguish between saving a respected life (which is compulsory in Islam) through medical treatment or financial support or something else and prolonging life artificially. 7 For example, suppose that someone is dying definitely because of an advanced cancer and lack of cure for him and that the most can be done for him is using some medicine just to keep him alive for few days. The cost of the medicine is so high which is not affordable for the whole family and they will be greatly troubled. Is it necessary for the patient himself or for his relatives or for the others to take this measure? Or if this can be done by a very painful and major surgery is it necessary for the patient to undergo such an operation while there is no possibility of cure? I think it seems reasonable to suggest that “the physician and the family should realize their limitations and not attempt heroic measures for a terminally ill patient in order to prolong the artificial life (or misery). The heroic measures taken at the beginning of life (i.e. saving a premature baby) may be more justified than at the end of a life span, though each case has to be individualized” (21).
At district and provincial hospitals respectively, CO roles were often expanded as COs with appropriate spe- cialist training worked as SCOs in their area of qualifica- tion. SCOs generally were then able to restrict their scope of practice to their area of specialization. They had greater autonomy that included being the ‘lead’ clin- ician when treating patients referred to them and also performed minor surgical procedures. As described in the quote below, these officers routinely work in special- ist clinics (ENT, ophthalmology, and so on) or in chest and lung clinics that offer treatment of tuberculosis sup- ported by the National HIV/AIDS control programme (NASCOP). However, any CO (general or specialist) who has undergone training to offer ART could work in clinics providing HIV/AIDS treatment (that is compre- hensive care clinics). In addition, SCOs also mentored students and interns attached to the hospital while those specialized in chest and lung diseases were required to supervise lower level facilities that offered TB services. The following two quotes from one respondent highlight these issues.
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There have been major advances in interdisciplinary and preventive medical management of individuals with Down syndrome. Improved medical care, laws ensuring appropriate education and related services for the disabled, and slow changes in societal attitudes have brightened the outlook for individuals with Down syndrome (Van Dyke et al, 1995). An active life, including participation in work, social, and worship environments, is now possible. As individuals with Down syndrome take their place in these areas, we can expect some of them to assume the sexual roles that the general population takes for granted: lover, spouse, parent (Van Dyke et al., 1995). Review of developmentally appropriate sexual issues should be part of the medical and
Also contributing to reports of experiencing fatigue, staff described numerous other large changes taking place at the hospital over the years, in addition to the redevelopment: “Basically for seven years we’ve been undergoing changes since I’ve been here. It is utterly exhausting having this many changes all the time” (GS1). This highlights that while this study captures prospective insights to the change, change is constant in health care. While the move into the new building has not yet oc- curred, the move is part of a broader organisational change grander than the physical expansion of infra- structure. While this was a major concern for many staff, some of the senior medical staff dismissed this as being an issue, suggesting constant change is part of health care and should not lead to staff feeling worn out: “I think once you get to my level you get good at kind of jumping through hoops… As you get more experienced, you just go with the flow a bit more” (SURDR2).
Each encounter was assigned an “attribute.” The attribute is the general description of the nature of the problem necessitating care coordination. For example, an encounter was considered “typi- cally medical” when it was characterized as being related to a physically based, organic problem. Issues related to breathing problems, gastrointestinal complaints, medication use, rashes, in- fections, headaches, immunizations, etc, represent “typically med- ical” attributes. Nontypically medical attributes were ascribed to problems based on psychosocial or mental health; developmental, behavioral, educational, legal, judicial, and nutritional issues; and referral management within managed care systems.
sectional sample within the study, “due to general medical condition”, “substance induced mood disorder” (to include prescribed medical interactions) and “bereavement” may be of particular interest for consideration. Next, five of nine categories would need to be “met” (see Table 3.1) to include the following conditions: (1) symptoms do not meet criteria for “mixed episode” (2) symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning [GAF] (3) symptoms are not due to direct physiological effects of a substance [drug of abuse or medication] or general medical condition [link to MDD] (4) symptoms are not better accounted for by bereavement [loss of a loved one, symptoms persisting longer than two months or characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation] (DSM-IV 2000).
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There are many potential benefits of incorporating computer-based psychological treatments (CBPT) into community-based mental health services (including drug and alcohol clinical services). The standardized nature of automated treatment can improve the transportability of evidence-based practice from research to real-world clinical environments, and it lowers many of the barriers people face to accessing care. The technology also offers a level of convenience not generally available via therapist- delivered treatment (such as 24-hour access to treatment, no wait-lists). Within a stepped-care framework, CBPT offers an alternate entry point into mainstream treat- ment or a credible alternative for people who cannot or choose not to seek treatment from existing mental health services [3,4].
means that history and past politics have been important to the development of emergency care in hospitals. Nevertheless, it is hoped that activity based funding will be introduced at some stage in this area. Although activ- ity based funding is commonly used to fund acute hos- pital care, there is not a large body of research about the impact of this funding mechanism on efficiency, particu- larly in emergency and urgent care , and the findings vary between countries and contexts  . Further re- search on costs, cost-effectiveness and the implications of various staff-mix configurations are needed to ensure that activity based funding captures the complexity of cases treated in ED and urgent care settings appropri- ately . There may also be potential for more integra- tion of services through the relatively new hospital networks. Ambulance services are funded separately for National Ambulance Services (outside of Dublin) and the Dublin Fire Brigade (within Dublin). GPs are entirely private sector agents but are funded by Government through a contract for those patients who have medical cards. Their contract is based on a mix of per capita pay- ments and fee for services . The out of hours and emergency care that they provide for medical card pa- tients is funded on a fee for service basis by Government. Private patients (around 60% of the population) who wish to receive such care, must pay the full costs. Individuals who wish to seek private emergency care may do so in the major cities, according to their own means and private in- surance status.
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The lack of progress in understanding and determining MDOs and in particular MDOs in primary care may be attributed to several factors. The diagnostic process often spans multiple health care settings and involves different professional staff groups, which in turn intro- duces myriad challenges, such as co-ordinating care and managing the timely and secure communication of pa- tient information. Furthermore, diagnoses are made dur- ing time-pressured consultations within primary care settings, where providers are often remain unaware of ultimate patient outcomes . As a result, it is hard to detect MDOs, ascertain their underlying causes and, ul- timately, very difficult to prevent them . Consequently, measuring MDOs and calculating a reliable ‘error rate’ is challenging. To date, the incidence of MDOs has been es- timated using at least eight different methods . Each method has its associated strengths and weaknesses, but retrospective manual chart or patient record reviews are considered the ‘gold standard’ . Although laborious, the method allows for the overarching diagnostic process to be traced and account diagnoses that evolves over time. Identifying, measuring and understanding MDOs in primary care is the first step in developing policies and interventions to reduce harm and improve patient safety in this area. At present, we have no reliable estimates of diagnostic error in English general practice with which to formulate any such policies or interventions, hence the need for this work.
were introduced. A single person with an income of €700 per week (€36,500 per year) or a couple with an in- come of €1,400 per week (€73,000 per year) were no lon- ger entitled to a free medical card . Budget 2014 reduced the income limits to €500 per week for a single person and €900 per week for a married couple . This policy change will reduce the eligibility rates and reduce overall coverage rates, holding all other factors constant. Since the introduction of this policy change, it is difficult to quantify the impact of this policy as the Irish economy is still in recession with more people eli- gible for the medical card due to their economic circum- stances. Due to the three drivers of future health costs as mentioned above, GMS coverage is likely to increase thus increasing health costs. To counter this increase, the Irish government may need to consider further de- creasing the income limits for medical cards or other measures.
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