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December 2012 (Volume 90)
December 2012 | Bradford H. Gray
The ﬁrst article in this issue of The Milbank Quarterly examines a concept that is central to the journal’s mission: population health. In “Who and What Is a ‘Population’? Historical Debates, Current Controversies, and Implications for Understanding ‘Population Health’ and Rectifying Health Inequities,” Nancy Krieger contends that populations should be understood in much more than statistical terms. That is, to be meaningful for research and policy purposes, populations need to be understood in historical and relational terms, not as simple aggregations. She argues for what she terms “critical population-informed thinking.”
Krieger traces historical thought about populations, beginning with the nineteenth-century Belgian statistician Adolphe Quetelet and his concept of the “average man” and then moving up to genetics and contemporary breast cancer epidemiology. She summarizes her analysis in propositions about the meaningfulness of statistics about populations, the role of social structure in affecting measures of populations, the distinction between study participants and populations, and the need for “meaningful choice” in the selection of study participants. Krieger’s article is an elegant reminder of the need for care in thinking about and studying populations.
The next article in this issue examines an innovative response to the all-too-common problem of harm to patients resulting from the medical care they receive. Under this new approach, which was explored initially at the University of Michigan Health System, health care organizations (1) actively try to find events that have resulted in harm to patients and to identify those resulting from negligence or error; (2) give patients and families a full explanation of the problem, apologize, and offer compensation when standards of care have not been met; and (3) encourage patients and their families to seek legal representation. In “Disclosure, Apology, and Offer Programs: Stakeholders’ Views of Barriers to and Strategies for Broad Implementation” Sigall Bell, Peter Smulowitz, Alan Woodward, Michelle Mello, Anjali Mitter Duva, Richard Boothman, and Kenneth Sands describe what they learned from key informant interviews with individuals in provider and liability insurance organizations about the possibility of wider use of the approach. They did not discover any barriers that seemed insurmountable. The authors concluded that the “disclose, apologize, and offer” model could transform how medical liability and patient safety are treated.
The next article in this issue is “Simulated Patient Studies: An Ethical Analysis” by Karin Rhodes and Franklin Miller. The article was stimulated by a political controversy in early 2011 arising from a press account of plans by the U.S. Department of Health and Human Services to contract for a study that could help anticipate the consequences of the Medicaid expansion specified in the Affordable Care Act. The study’s design was straightforward. Researchers posing as prospective Medicaid or privately insured patients were to telephone physicians’ offices to see if they could get an appointment. The study was aborted on political grounds, but Rhodes and Miller are interested in whether such research designs should be viewed as ethically acceptable. They conclude that they are, provided that the research is “minimally invasive” and adequate confidentiality protections are in place. They also looked at whether such methods should fall under the current regulatory regime for research involving “human subjects.” They concluded that the answer to this question is debatable.
The next article in this issue is “National Newspaper Portrayal of U.S. Nursing Homes: Periodic Treatment of Topic and Tone” by Edward Miller, Denise Tyler, Julia Rozanova, and Vincent Mor. Interested in nursing home policy, the authors started with the premise that the views of both the public and policymakers are affected by press accounts. They thus set out to see how nursing homes were portrayed in the decade ending in 2008 in major newspapers in New York, Washington, Chicago, and Los Angeles. The major topics were quality, financing/cost, and negligence/fraud. Negative portrayals of nursing homes outnumbered positive portrayals by a ratio of five to one, though this varied by newspaper and over time. The authors concluded that the press’s depictions of nursing homes stigmatized nursing homes (and the people who worked and lived in them), thereby complicating policy efforts to integrate care across settings.
This issue ends with “The Use of Cost-Effectiveness Analysis for Pediatric Immunization in Developing Countries” by Cindy Low Gauvreau, Wendy Ungar, Jillian Clare Köhler, and Stanley Zlotkin. Noting that the need to choose among policy alternatives is particularly important in countries with limited resources, the authors did a literature review to document when and how cost-effectiveness analysis was being used to guide pediatric immunization policy. They describe the ways that cost-effectiveness analysis has been used in both industrialized and developing countries, arguing that the limited availability of cost-effectiveness analyses in developing countries has led to the undervaluing of pediatric interventions. They conclude with recommendations to address the problem, including suggestions for donor countries and organizations.
Bradford H. Gray
Author(s): Bradford H. Gray
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Volume 90, Issue 4 (pages 631–633)
Published in 2012
Who and What Is a “Population”? Historical Debates, Current Controversies, and Implications for Understanding “Population Health” and Rectifying Health Inequities
Notes on Contributors