Research Topics: History Of Nursing

Comparison of Cities: Hong Kong and London

Introduction Cities are economic and social systems in space. They are a product of deep-seated and persistent processes which enable and encourage people to amass in large numbers in small areas. Surplus products, generated outside the city, provide the basic means of support, but viability and prosperity also depend on the existence of social arrangements and institutions through which cities are regulated and managed. So powerful and pervasive are the forces of urban formation and growth that they presently concentrate over three billion of the world’s population in towns and cities. The urban world is distinctive in socio-economic as well as in spatial terms. Despite the infinite and intricate variations of tradition and culture that exist within and between nations, cities appear to have, and to be acquiring, more in common than they have differences. Urban places have many similarities of physical appearance, economic structure and social organisation and are beset by the same problems of employment, housing, health, transport and environmental quality. The elements in many urban skylines are the same, as commercial and residential areas are increasingly dominated by high-rise developments constructed in international styles. Streetscapes across the world are adjusting in the same way to accommodate the needs of the ubiquitous car, so cities are fast losing their individual layouts and architectural identities. Within buildings, workers do the same sorts of jobs, often on the same makes of computer or machine, and manufacture goods and services to the requirements of world markets dominated by a small number of global producers.  What can be seen in a city is attributed to what images portrayed by the cities.  In this manner, the main goal of this paper is to provide an analysis on how the impact of social, economic and political differences of two cities constitute to the urban form shown by the city.  The cities that will be given emphasised in this paper are Hong Kong and London.  In this impact analysis, the discussion will include the political situation of each city as well as the social and economic condition of Hong Kong and London.  After which, the analysis of the relation of these aspects to the urban form of each city will be provided. Overview of the City Hong Kong City  Hong Kong City is has a population of 6, 787, 000 people with a total land area of 1,001 km² (386 mi²).  Hong Kong has been known to be a former British Colony.  In was taken by the British Empire in the 19th century and was given to China in 1997.  Hong Kong means (Fragrant Harbour).  Hong Kong today is regarded as the major seaport, business hub and financial centre of Asia. The Hong Kong city is also recognised as the home of many business tycoons and Giant Corporations as well as poor illegal migrants.  It is said to me the city of extremities, opportunities and busy street life (Fong & Tung, 2001). Political, Economic and Social Aspects  Hong Kong’s success is legendary. After a meagre start as a British crown colony established on fishing villages of nearly barren rock in 1842–part of the spoils of victory from the Opium War–Hong Kong has become a cosmopolitan city-state of global significance. Though it ranks ninetieth in terms of population, it is the world’s eighth largest trading economy, with a per capita income higher than some developed countries including Britain, its colonial master. With eighty-five of the world’s top one hundred banks, it is one of the five international financial centres. Hong Kong’s miracle economy has made it one of the Four Little Dragons of East Asia, a title shared with Singapore, South Korea, and Taiwan. Finally, Hong Kong is the undisputed gateway to China, which is Hong Kong’s largest trading partner (Hong Kong is China’s second largest trading partner after Japan) (Findley, 1993). Hong Kong serves as a powerful catalyst for the economic development of South China, where Hong Kong companies employ over three million workers in neighbouring Guangdong Province alone. Thus, it is natural that most Hong Kong people see their future as inextricably linked to China’s economic growth and political modernization. Hong Kong’s developmental experience is worth emulating. Yet, its free trade, market economy and open society have been in stark contrast to its lack of a full-scale, genuinely democratic form of government. In this sense, its prosperity and stability within the context of freedom without democracy have been the hallmarks of British colonialism–indeed; the colony is a remarkable case of borrowed place, on borrowed time, and with borrowed people (Cochrane, 1995). In late 1984, Hong Kong was compelled to embark on its most dramatic historical change. The Sino-British Joint Declaration mandated the end of British rule and the resumption of sovereignty by China on July 1, 1997. The policy toward Hong Kong’s sovereignty retrocession is based on the” One Country, Two Systems” formula and has two principal objectives: China’s national reunification with Hong Kong, which would set the example for Macau and Taiwan, and the maintenance of Hong Kong’s stability and prosperity so that it would continue to contribute significantly to China’s economic reform and modernization. The 1984 Sino-British Joint Declaration promises to preserve Hong Kong’s existing legal, economic, and social systems and lifestyle for fifty years from July 1, 1997, when the colony is to become a Special Administration Region (SAR) of the People’s Republic of China (PRC). Furthermore, this promise became enshrined in the SAR Basic Law which codified the constitutional framework that is to give effect to the promised “high degree of autonomy” with “Hong Kong people ruling Hong Kong,” as well as to regulate central government-SAR relations. The Joint Declaration explicitly calls for the Hong Kong SAR legislature to be fully elected–a major departure from the (until 1985) totally appointed colonial legislature (. As such, preparation for the future SAR political system necessitated the most drastic and fundamental change in Hong Kong’s colonial polity. These constitutional and electoral reforms triggered controversies and confrontations within the local community and between Britain and China. The resulting tensions and conflicts that have characterized the transformation of Hong Kong since the mid-1980s, unfolded under the ever looming “China factor.” The China factor has become an overwhelming influence on life in Hong Kong. It is the single most dominant force shaping Hong Kong public affairs, government decision-making, and policy implementation as well as Hong Kong’s external links and global interactions. This situation gave impetus to the further development of Hong Kong’s new political culture. A growing civic awareness, political activism, and articulation of social value orientations began to have a decisive effect on the rising expectations and future perspectives of the Hong Kong people. Meanwhile, the increasingly close relationship between Hong Kong and the Chinese mainland in trade, manufacturing, investment, transportation, finance, skills and technology transfer created an intimate economic interdependence, even integration, between the two. In this respect, the China factor remains the principal force underwriting much of Hong Kong’s economic prosperity. The China factor has also been the accelerator, stimulant, and even midwife to the processes of decolonization, localization, internationalization, and democratization which are still unfolding in the current transition. This has given rise to identity awareness among the local populace, who have come to see themselves as Chinese nationals with aspirations for a more modern, post-colonial, Chinese community that is self-conscious of its heritage. In this sense, the China factor has promoted a fundamental change in Hong Kong’s polity and socio-cultural mentality. City of London  London has a total population of 7, 172, 036 in city and 11, 850, 000 in metro it has a total land area of 1579 km2 (609 mi2). London is known to be one of the most energetic, cosmopolitan and dynamic cities in the world. In addition, London is also regarded as a hub of politics, culture, history, finance as well as learning and entertainment. This city is moderately low rise, having a tall buildings clustered in the City of London and Canary Wharf.  London also has a mix of eye-catching architectural landmarks including St. Paul’s Cathedral, Tower Bridge, Palace of Westminster and the Tower of London.  The city has also landmarks which have a new breed of astonishing modern structures such as BA London Eye, City Hall and 30 St Mary Axe. Politics, Economic and Social Aspects              Nineteenth-century London was a place of firsts and superlatives: the capital of the first industrial nation; the largest and richest urban agglomeration in the world; the first city with extensive mass suburbanisation, to name but a few. It was also a city of contrasts which could be seen in the extremes of wealth and poverty; in dynamic, successful industries alongside declining ones; in people at leisure and those locked in the most menial drudgery; and in new architectural and civil engineering wonders next to acres of dilapidation (Fainstein, Gordon & Harloe, 1992). Identifying such distinctive features and how they changed over time is at the heart of any narrative urban history. Yet, the characteristics of any city cannot simply be described. There needs to be an explanation of how things came about and there is no shortage of explanations within the wide literature on London’s history. What is noticeable, however, is how little use has been made of modern economic theories, particularly those falling within the ambit of urban economics. To claim this is not to beat the drum of professional jealousy nor to suggest that economics can explain all, but rather to suggest that developments in nineteenth-century London were mainly stimulated by what are now reasonably well-understood economic processes. This viewpoint is at variance with many histories of London because they tend to identify uniqueness in the character of the metropolis at the centre of their explanations. Uniqueness can certainly be found and as a theme it has a long pedigree. The capital city of the United Kingdom, the leading world power by the 1820s, was a special place that caused wonderment at its vastness. At the same time, its scale filled many contemporary observers with horror, mixed with pride at the scale of the human endeavour needed to create it. Yet, the causes of the growth of London were generally regarded as something of a mystery. Other cities in Britain, like Manchester, had burst forth out of virtually nothing at the end of the eighteenth century, but they could be seen to be a product of the new industrial capitalist society. The same forces transformed London but this was not so obvious because there were few of the features that spawned the industrial towns of the Midlands and North. Near it were no coalfields; there was no intense specialisation in heavy industry or textiles; nor was London even a focal point for a network of surrounding industrial towns (Giradet, 1990). Only one thread of argument seemed to explain London’s existence. Despite all its apparent modernity, the metropolis was a unique throw-back to a bygone mercantilist age: with its scale generated by the conspicuous consumption of the wealthy, the world-wide tentacles of the City and Empire, and a terrible exploitation of a mass of poor people. Uniqueness was clearly important within this interpretation, because, if it was extrapolated to the nation as a whole, this view was revolutionary in content but, when localised to the capital, it was believed by many who were hardly radical in their general politics. This explanation had a powerful effect on what was seen as London – an image that has persisted in much of the literature until today. The capital was like Wilde’s Dorian Gray. The proud architectural and cultural face of Georgian, Victorian and Edwardian London existed because of the hidden picture that was the inner-suburban industrial districts and the poverty associated with them. The problem of London was contained in the misleading geographical metaphors of the West End versus the East End and the City versus Industry (Haughton & Hunter, 1994).  Impact Analysis  Urban life started over four thousand years ago, when human beings combined specific building technologies with ways of organising society to create densely populated living spaces. Since then, many different types of society have found urban living useful, and technological change has made the potentials of city existence manifold apparent. Yet, it was not until the nineteenth century that countries larger than city states became structured as predominantly urban ones. Britain was the first country to experience that shift, and London towered above all its other cities in size, wealth and productive capacity – housing over a fifth of England’s population by 1900. The cause, of course, was associated with the development of modern capitalist societies – a process in which Britain took the initial lead.  Urbanisation went along with industrialisation and sustained economic growth. These inter-linked processes subsequently spread through other countries and continue to encompass more areas of the globe.  In today’s Third World can be seen the fastest urban growth rates ever, and it is estimated that over half the world’s population will live in urban areas within a decade, so the process looks set to continue for the foreseeable future and undoubtedly beyond. In many senses, therefore, the growth of London in the nineteenth century represents the first example of this modern phenomenon and its economic history is interesting for that reason alone. The technical and organisational characteristics of capitalist cities, moreover, make them highly amenable to economic analysis. Clustering does not arise in such societies through some pre-conceived plan but through the responses to market forces of a multitude of individuals and firms. The foundation of urban organisation is consequently that of markets – the stuff of economic analysis. The strong positive impact that cities make on the productive potential of society overall, and the social ills which go along with it, in addition, make an economic analysis of cities important for an understanding of general economic development. (It is one of the professional paradoxes of economics that modern growth theory has tended to ignore the urban dimension when looking at the causes of economic growth.) The first was that London’s population began to expand continuously at the fast rate of around a fifth every decade. This growth continued for over 150 years until the suburbs spilled far beyond the juridical area of the metropolis. City growth, in other words, was a self-sustaining process – no longer linked to government and aristocratic behaviour but to market relations.  The second new characteristic was that traditional work practices had noticeably given way after centuries of slow dissolution, so that nineteenth-century London industry was, in the main, openly competitive and exhibited overtly capitalist behaviour. In addition, it was particularly significant in nineteenth-century Britain. There was a marked specialisation of the country’s regions in particular economic activities and the rapid appearance of major cities in the areas where manufacturing became important. London, therefore, was not alone. An array of other urban areas simultaneously existed, in what came to be called ‘conurbations’, but with notably different features from each other and the metropolis – reflecting the differing industrial specialisations of the regions in which they emerged. London, consequently, was the first amongst many. This influenced its development and provided a means by which to compare its development.  Institutions were also significant with regard to social policy, labour markets and other key areas of the economy, such as the City, the docks and the structure of consumer industries. London government during the period, similarly, is often regarded as woefully inadequate because of the earlier institutional framework from which it developed and the lack of change in it. This negative description may be debatable but the impact of urban governance on infrastructure provision, private as well as public, was none the less substantial. In the case of Hong Kong and London both city have their urban style or urban form.  As can be seen in the above discussion, Hong Kong has become one of the world’s busiest cities in the world. Hong Kong represents an outstanding case and urban form of its own. This city is unique because it represents an extreme case of overcrowding, rising population growth, shortage of land resource, intensification of land-use activities, hampered by an absence of raw materials and natural resources. Yet, the story of Hong Kong as a Sky City invites wide interest from urban designers and managers to avail clues to successful managing of limited resources, and more importantly the ways to maintain a vibrant and rich living and working culture in a vertical land use approach, the vertical dimension of which amaze the world at large.  Hence, the urbanisation of Hong Kong was due to how the city manages its resources and also the economic stability of the country as well as its strong social structure which are mainly affected by the Chinese structure. Conclusion  The urban world is dominated by a small number of centres that are the command and control points for global capitalism, the world’s dominant economic system. Such centres are distinguished not by their size or their status as capital cities of large countries, but by the range and extent of their economic power. They are the locations for the key individuals, institutions and organisations that manage, manipulate, dictate and determine the formation and reproduction of capitalism across the world. These attributes give such cities a disproportionate and exceptional importance, so that they occupy dominant positions in the global urban hierarchy. So pre-eminent is their status and so powerful and pervasive are their influences that many analysts argue that they merit designation as world cities. Analysis shows that Hong Kong and London as a city have their own political, economic and social differences. These highlighted differences have made the two cities become what they are known today.  Although both can be said as strong and competitive cities, each has constituted its own reasons for urbanisation. Historically, the influences of the British Empire to both countries can also be considered as one factor why these cities learned to manage all its resources well may it be in political social and economic aspects.  Word Count: 2996, excluding references Credit:ivythesis.typepad.com

Comparison of Cities: Hong Kong and London

Introduction Cities are economic and social systems in space. They are a product of deep-seated and persistent processes which enable ...

MARKETING: BANKING AND FINANCE IN UNITED KINGDOM

Banking and Finance in United Kingdom   Introduction               The omnipresence of global trends and innovations debunk the idea of business monopoly and empire states. Today, the trends are set to maximize the potential of human powers by trivializing simple phenomena in order to fashion complex and subtle effects. In the minds of prominent sociologists and philosophers these trivialization of occurrences brought about by man’s deepest desire of uncovering the truth and meaning of life. However, our correspondence and connection with the truth is indirect and diluted which can only be accessible via representations and constructs. Hence, the necessity, though, not necessarily is, of excavating the truth embedded on phenomena became an ordinary human laborious pursuit.             Moreover, due to rapid changes on various aspects of human life our reactions vary depending on the way we perceive it, while forming effective and efficient mechanisms become a mechanical elocutionary act. This fact is paralleled with the nature and condition of business operations wherein technology dictates in setting the trends and innovations. Moreover, such despotic nature of technology invigorates the force and power of globalization to deeply penetrate all human spheres of interaction. Historical antecedent on business evolution             The incorrigibility of technological advancement obviously shoves business operations and economic modes to be flexible. Here, business movers, analysts, strategists, theorists, scholars, and other personalities with significant role in business management and economic functions should be shrewd enough to incline their attention to the unexpected events and surprises which charily   crafted by setters of global trends and innovations. Therefore, in business operations incessant assessment, evaluation, and revision of organization’s strategies, programs, standards, objectives and goals are imperative. So much so, that such relentless observation should have mixed with collective effort and work of all representatives and members of the giving organizational body.             Marshalling momentous events in the cycle and growth of civilizations can be mapped using the scalpel in detecting the contourical locations of facts concerning economic struggles contained in history. The inseparability of economic, social and political factors is embedded in human struggles as recorded in the annals of olden times.             Hence, the evolution of marketing processes and modes of producing goods and services was not only invented during the recent centuries but, was already present when the first civilization came to existence. Although, no proper and serious study made at those times, recent discoveries and theoretical principles were, I believe, are products of the precedents civilizations. Meanwhile, not until       ’s revolutionary theory which led to crumble the traditional management process and replaced it with a scientific-based management process stupefied managers, capitalists, and movers of his time.                 Inseparability of social domains and its eventual effects   Meanwhile, let us end these historical actuations and pursue our articulations on the recent scenario affecting the domain of business and marketing. The ascension of skyscrapers, business towers and trade centers in different places all over the world signify the dominance and control of business sector compared to other social fields. We can argue then that business operations become instrumental in human living without which the height of survival maybe reduced to a lesser amount. In contrast, business as a mode of survival for human beings inexorably becomes an exploitative and dominative domain wherein human resources and manual labor are alienated from the true value of human dignity and worth. Despite this reality, human resistance is tempered by the need to survive and to further acquire material possessions. Likewise, as man’s social and material needs increases, new business production and services schemes are emerging in response to these increasing demands.  It is in this context, which many business types are emerging due to human needs. On this account, technology, human needs, and business inseparably affect each other’s domains, more so, tends to cross each other’s boundaries to penetrate each others’ systems. The chain of reaction cannot be dissolve easily. This idea under capitalist’s viewpoint, the plethora of ever-increasing needs is the façade of one fundamental need: the pressing need for money. Now what dictates business firms and increasing expenses on research to track down recent trends is because of such need. The Case Study             In this paper, I would like to present a case analysis on the emerging trend or might be considered as a prevailing economic drawback on the banking and finance system in United Kingdom.             The objectives of the study is to examine the present state condition of United Kingdom’s banking and finance environment by drawing one popular banks as a case for diagnosis. Moreover, using management measurements and methods of analysis like        five forces, this paper hope to find the problems ranging from customers’ behavior, marketing system strategy and emerging global trends, and in turn, propose alternative marketing strategy in order to medicate the existing drawback. The scope of the study will only be limited on the issue about the UK’ s banking and finance system analyzed using various methods of investigation, an internal auditing on Lloyds banking system and financial operations,  the global trends which directly or indirectly affects its business banking operations, and the financial market in general. Significance of Financial Market             In the norm of business and economic growth, financial system inevitably plays a vital role. We are told that financial market is embodied with sophisticated systems in which are observed carefully by financial and marketing connoisseurs. The role of financial system is to be an intermediary between lenders and borrowers, in this sense, for example in banking business “providing a menu of saving vehicles with differing risk and return characteristics, and helping investors find the financing they need, taking into account the returns and risks on the projects they wish to undertake (2003 p.2).” Banking industries and other similar forms can be accounted as financial markets in which are responsible for giving financial assistance and services to borrowers, lenders and investors.                 in his book     published its English version in 1934, provided an elucidation of the relevance of financial markets as entities significant in the economic development:             The banker is not so much primarily a middleman in the commodity purchasing power as a producer of this commodity. He stands between those who wish to form new combinations and the processors of productive means. He is essentially a phenomenon of development, though only when no central authority directs the social process. He makes possible the carrying out of new combinations, authorizes people, in the same society as it were, to form them. It is the ephod of the exchange economy (p.74).                           Furthermore, such role of financial development in economic growth posits a great significance in the development and progress of a society in general.   again underlined in his speech delivered after his audience in Brazil that:                         Financial development is at least correlated with economic development and that a sound and sophisticated financial system promotes the efficiency of investment and economic growth in the market economy. It is obvious that a poor functioning financial system can hamper economic growth and development (2003 p.5).               Clearly, financial markets in general help economic development and growth of the society. Conversely, if financial system is poor and the governing programs are no longer effective can lead into a decline of economic growth. Moreover, rapid technical progress and trends in global financial systems can be harmful in the national and local financial markets if and when no proper procedure is employed.             Therefore, in underlining the significance of financial market, we come to recognize its vital role in the economic development and intensification. However, relevant to such status is the prevailing drawback of UK’s banking and finance status in the present time. Does this show the obsolete and antiquated strategy on banking and finance system or only a matter of lapses in medicating the unseen forces spread by global trends and innovation? It can be considered as both valid questions in which it somehow impaired the prevailing financial system that caused a drawback in banking and finance business of UK. Question No.1: Examine the internal environment for the UK Banking and Finance and compare it with world trends.   A. Banking and Finance in United Kingdom             In this case, we are going to analyze the status of banking and finance in United Kingdom using the IMF report done in 2003. This report is entitled:       . Although, the report was made five years earlier, it somehow reflects something relevant in this present state.             According to IMF overall stability assessment on financial system, United Kingdom’s sophisticated financial sector poses a sound and highly developed financial institutions, markets, and infrastructure (2003, p.7).  This positive feature of banking and finance was supported by the financial stability policy framework in which being practiced on how to sharpen focus, accountabilities, transparency and encourage and facilitate coordination between the main players. Moreover, the less prescriptive mode of supervision by the United Kingdom is highly treated compared to some other countries, but “with relatively more emphasis on policies to promote good corporate governance and market discipline (2003, p.10).” However, the changing financial landscape brought a rapid change on the financial system operations. In (2006) speech about Financial Risk in the UK – Issues and Challenges Center for the Study of Financial Innovation Roundtable, identified the challenges posed by technological innovation in financial and banking operations. The technological change caused financial innovation, cross border financial consolidation and the increasing demands of investors for better performance have had a profound effect on financial markets and institutions. Further he concurred:             The changing nature of financial activity is illustrated by development in credit derivatives markets. The availability of these instruments is enabling a change in the nature of banking itself towards business models based on origination and distribution rather than the retention of credit risk. The notional amount outstanding on CDS contracts globally reached trillion in 2005, up from billion in 1996. and the issuance of asset-backed securities in the UK, which involve parceling up and selling different claims on pools of assets such as costumer loans and mortgages,  has risen to some 5 billion from .5 billion in 1995 (, 2006;5).               The banking and finance system of United Kingdom is vital in many points. The financial sector according to IMF report is a large contributor to domestic economic activity, and has a major international orientation. IMF reported: “In 2001, the financial sector contributed 5.2 percent of GDP, and net exports of insurance and financial services represented 1.3 percent of GDP (2003, p.13).” The four major U.K. – owned commercial banks accounted for about 24 percent of the resident banking activities in the U.K. Furthermore, it has a diversified set of claims against domestic and foreign counterparts. The insurance and pension funds account for nearly another third of the financial sector’s contribution to GDP and employment. The U.K. general insurance industry is the third largest in the world “accounting for about 10 percent of worldwide net premium income” and consists of insurance companies, the     ’s insurance market, underwriters, brokers, and intermediaries.             In the last note, U.K’s recognizable ability to develop and adopt effective strategies and programs in making its finance and banking institutes grow is magnificent. However, even if U.K ‘s banks appear to be sufficiently lucrative and capitalized to be able to soak up, without systematic distress, the fatalities that might arise if the potential risks above were to crystallize, yet financial soundness indicators need to be interpreted with some caution. The unpredictability of issues and occurrences can cause fatal effect if and when no cautionary awareness held at hand. Hence, although financial and banking system of UK presents a development positive to the financial stability, we cannot assure the constancy of such progress if we have to stop reinventing and assessing the system. A1. Examining U.K.’s banking and finance external environment using PESTLE analysis             In line with this project, let us examine the environment of banking and finance in U.K using       analysis as a tool that can aid organizations to identify and understand the external environment in which they operate. The use of such method of analysis allows us to investigate systematically the external environment.             Using the      analysis let us identify major external elements which affect the operations of banking and financing activities.             Political factors affect much the activities on banking and finance. The governmental system as well as the formulation of public regulations and policies regarding banking and finance are held primal to banks and finance institutions. For instance, the European Union aims to create a common financial market and the harmonization of their regulatory schemes. Such political design inhibits unhealthy competition between members of the group rather advance their collective interests. The attempt of political convergence may not be beneficial to all member of the union yet a minimal convergence can be produced out of such political design since differences sometimes create imbalances and conflict.             In the banking and finance industries of United Kingdom, the role of government and good governance are important. The making of national regulatory system, banking and finance laws, rules, and policies can be as important as the economy of the country. Government officials and law and policy making body play a crucial function in making the finance sector robust in its operations and services.             However, since the world today is no longer fragmented rather trying to bring each regions in close connection with other regions making them as one and homogenous, the trends now are no longer set in a national, local, or regional level but in a global view. Hence, United Kingdom with its distinctive and effective laws, regulations, and policies on banking and finance system considered the effects of global trends wherein a more adaptive and strategic policies and laws on finance are employed. Such ordinance dictates by the global circumstance, make the United Kingdom’s banking and finance institutions create enhancement strategies and techniques on how to maintain a financial stability most especially in the banking operations.             The Socio-economic factor is an external element in which any business organizations and institutions should be aware of. The social issues present in one’s society are substantive elements in which affects all human fields of interaction. Thereby, issues concerning culture, human behavior and expectations elicit a need for social reengineering. On the other hand, economic status and its given system can be deterrent for development if and when no proper economic programs and policies are employed.             In any business organizations or financial institutions such social-economic factor are vital to consider. The importance to see the need for social and economic growth should be constant. In banking and finance system of United Kingdom, various programs and services are offered to customers in order to satisfy their social and economic needs. For example of financial system programs in which United Kingdom offers are the insurance, security and payment systems supervision. These programs with global policies offered its customers and beneficiaries a higher social and economic status.             The technological factor as external to the environment of banking and finance operations should be considered. The entrance of internet to the public world drastically creates a technological change. In the article of     entitled:     , he articulated how technology changes the process of banking system in the United Kingdom. The impact of technological change costs for the UK clearing banks’ method of payment: The methods of making payments in the UK have shifted considerably during the 1990s with a strong trend towards automated settlement and away from paper transactions. This trend is expected to continue into the 21st century, with major gains being achieved in bank profitability as customers move from high cost transactions, such as cheques, to low cost methods of payment such as debit cards. It is estimated (by) that almost half the 60 000 staff employed by the UK clearing banks is currently linked to money transmission services, with an annual cost of operating the system of approximately 4.5 billion pounds (, 2001;3-4)    This statement propose a clear understanding on how powerful technology is. Moreover, technology posses a dominant force in which powerfully dictates the trends in a global perspective. With this issue UK in its adherence and subjection to the global trends strategically position its banking and finance system on a place which it can be more effective and attractive not only on the local, regional or national level but to the international community as well. Here, other factors can be relevant for this analysis. The environmental and legal factors are potentially creates friction which attract attention from responsible individuals within an organization. In the banking and finance system of United Kingdom, the legalities concerning policies and regulations covered the finance and banks institutions are subject to the government authorities, political parties, and policy making bodies. Environmental issues are not only a responsibility of any civic organizations but of everyone being encouraged and invited to participate in environmental programs.  A.2.    ’s five forces: Identifying the location of power within an organization             The     ’s five forces are effective tool in identifying and assessing the power positioning located in the organizational structure. Using this method, let us examine the power location in the UK‘s banking and finance system. This analysis is contrary to the     method in which this aids us to see the internalities of organization’s environment.             In this analysis we are bringing five important forces that determine competitive power in a situation, namely: supplier power, buyer power, and competitive rivalry, threat of substitution and threat of new entry. In      s’ article entitle:     :         ? Investigated the evolution of UK’s financial system schemes and operations starting from a bank-oriented phase via a market-oriented era through the present securitized system symbolized the struggle to maintain and balance the power it acquired. One important feature in the evolution of UK’s financial system was the financial liberalization. Financial liberalization espoused by the     government attracts international business into London. However, domestic financial markets remained heavily controlled in order to maintain the macroeconomic stability (2001) explained that the major consequence of financial liberalization has been the erosion of traditional barriers, or segmentation, between financial markets and institutions. “The convergence and integration of financial markets facilitated a new round of innovation which led to the introduction of a whole array of financial products and services.” Furthermore, (1992; 465) in explaining that “the Financial Services Act of 1986 polarized distribution channels, which encouraged a variety of institutions to ‘tie’ themselves to insurance companies to sell contractual investment products, such as life insurance and pension.”  Again quoting  (1992) by: “The transformation of the financial system turned it into an engine of economic growth for the regional economy of London and the southeast of England. Yet, the polarization of financial power in one region meant that other regions were largely excluded from the benefits of financial liberalization.             The overheating of the economy has been attributed to the liberalization of financial markets and the fact that liberalization has made the financial system more open to the destabilizing effects of shocks to the international financial system.             The approach taken by regulators considered the degree of competition in banking too low to permit a satisfactory performance. In a certain sense regulators followed the structure-conduct-performance paradigm connecting free competition to a structure where the legal and administrative constraints were absent. The deregulation system has at least three characteristics in competition: the abolishing of regulatory constraints on the birth of new banks and on the creation of new branches, the opening up to foreign competition and the abandoning of the forced specialization between commercial banks and organized markets.             Recent work drawing on the industrial organization approach confirms that the banking sector possesses the idiosyncratic features of an imperfect market. Due to the product differentiation, consumers do not retort to low price differentials, long-term relationships favor consumers’ capture by banks, geographical market fragmentation has important implication for branching, the low number of banks favors collusive behavior, weak bankruptcy and hostile takeover threats lower the pressure on managers to productive efficiency.             Henceforth, we see how the forces affect the internal structure or environment of a certain institution. The rise of threats, competition and product or system substitution became an internal issue in which institution like banks and finance entities should be aware of. In United Kingdom, the technological advancement and global business policies and financial systems became more relevant in its own financial regulations as being set a while ago. Such responses like liberalization and deregulations were product of the intense demands of the foreign and global policies. This somehow polarizes market differentiation instead of unifying them into strong and unified markets.     A.3 Opportunities and Threats             One of the most fertile fields of analysis opened by and the and the economists is the study of the relations between banks and economic activity. For     , banks played a key position in the shift of the economic system from a lower to a higher level of economic activity. On the other hand, the       approach to banking and financial intermediation in business-cycle fluctuations views the banking system as a conduit through which agents’ perceptions of risks, and hence, business-cycle fluctuations, both influence and are strongly influenced by non-probabilistic uncertainty (, n.d. p. 3).             Given such knowledge on the role of banking and finance institutions, we can identify various opportunities as well as threats of the banking and finance system. The opportunities range from the basic services provided by banking institutions like lending, deposit schemes, loaning programs, and business financial assistance. Likewise, the most significant threats to the banking and financial institutions are the rapid changes in technology and consumers’ behavior. Thus, it provides a way of changing functions and processes. Many observers are prophesying the terminal decline of commercial banks and their long-standing deposit taking and loan functions. The information technology revolution brought a significant influence on the banks and the constant changing of trends would somehow be a perennial threat to the banking and finance system. A.4 Problems in the United Kingdom’s banking industry             In the 2002 article published online by      entitled:    :      is monopolistic and needs radical reform, posed UK’s prevailing problems with regards to handling financial system’s regulations and rules.         advised the government to bring to an end an auxiliary consolidation in the banking sector, in contention that the personal current account and small and medium-sized markets are already too concerted. For example, the takeover of NatWest bank by the Royal Bank of Scotland hoisted grave concerns. He further accused the four major banks of “abusing their position at the core of the UK banking systems to make excessive profits at the expense of retail and business customers.” His investigation on three areas like money transmission, services to personal customers, and services to small and medium sized businesses, revealed an evidence of competition problems ascribed to the high degree of concentration of market power in the hands of four giant banks. Such monopolistic and power control gives them the dominance in running interbank payments systems which handle all the cheque credit card and debit card transactions in the country with the “result that they are inflexible and hard to newcomers to penetrate, as well as failing to keep pace with the demands of e-commerce.” This showed the state condition of the banking industry in United Kingdom.             Moreover, in the article of    entitled:     , underlined the increasing competition and price competitiveness in the national and international markets. Such intense competition of the recent years affected banking sector and subsequently set fire for challenges. The reorganization processes are a reaction to the fact that banks have lost their leadership position in the traditional markets, and particularly to the impact of technological innovation.      and       argued:             In the last decade, market conditions in banking have undergone deep changes. On the demand side, customer preferences differ greatly from the traditional bank products (loans and savings). On the supply side, the globalization of financial markets is accompanied by their governmental deregulation. Both factors imply an increase in the number of competitors, followed by reductions in costs and narrowing of profit margins. Thereby, banks are faced with strong competition from non-banking companies, which also accentuates the competition between the banks themselves (2002, p. 46-47).             Under the pressure of intense competition, banks reacted differently on how they will resolve such problematic challenge. Some of them aims of rapidly improving profits, increased the income obtained from free based business activities or have ventured into high-risk segments such as security derivatives. A.5 Global Trends on Banking             Today many people are no less mortgaged to their bank, yet the notion of the bank as the commercial epicenter of a community is as much a part of history. The enormous and far-reaching developments in banking had a blurring of demarcations between different types of banking and financial industry activity (2002). Moreover, in the speech of (2005) underscored various trends in global banking. The trend from deposit banking to financial services, from balance sheet to off-balance sheet intermediation, from capital adequacy to capital efficiency, from physical to virtual distribution, from fragmentation to consolidation, and from data to information to knowledge, are global trends in banking and finance. Moreover, in the research done by the IBM Company sets out five emerging trends to reshape global banking. First, Customers take control. Customers will only be interested in service providers that can meet their very specific individual needs. Second, specialized niche competitors imply market consolidation will continue, making the giant banks even bigger. Third, is a new workforce. The need for productivity and efficiency will create new labor and work practices yet intense competition still constant. Fourth, the need to comply with globally enforced standards of transparency and accountability will force the adoption by banks of integrated, enterprise-wide systems and processes. Lastly, the role of technology will still be main agent for transformation and rapid changes in trends and innovation .             These global trends in banking only concurs a simple realization that in order to maintain the status and power of some traditional huge banks, the efficient measures and effective strategies in order to be adoptive and adjust to the global trends should and must be employed. B. Lloyds Bank: Its strengths and weaknesses             A further response to the intense competition in the global banking and finance business affected the traditional modes of financing and banking system in most of the countries, especially in United Kingdom. (1996) in his article in the  articulated the wave of takeover and merger activity between banks and building societies. One of UK’s finest and influential banks which took such trend is the Lloyds Bank merging with the Trustee Savings Bank. The creation of        was the beginning of a large scale consolidation in the UK banking market. The merging of two giant banks paved the way towards successes, strengthening its services and finance provisions to its customers and clients. The consolidation of brought a powerful financial system and banking operations in which extend its programs not only on providing financial services but also insurance plans. The group acquired    , a mutual life insurance company which made the group the second largest provider of life insurance and pensions in the UK. Moreover, Lloyds TSB acquired Chartered Trust from the Standard Chartered Bank to form Lloyds TSB Asset Finance Division which provides motor, retail, and personal finance in the UK. Lloyds has been investing heavily in its wholesale and international banking division, which put a strong performance, driven by corporate markets.             However, although, quite impressive was the performance showed by the consolidation of Lloyds TSB, we cannot escape the fact that it has its own weaknesses to deal with. (2005) article The Business: Lloyds TSB Needs to Rethink Radically Its System of Staff Incentives, Which Has Led to Customers Being Persuaded to Take out Loans They Can’t Afford, critiqued Lloyds internal management in dealing with its system of staff incentives in which believed to trick its costumers. The rhetorical actuations used by Lloyds TSB in attracting clients were criticized for its being unfair with the clients. Hosking cited the expose made by the BBC on the “irresponsible lending practices” at Lloyds TSB.             Monday night’s BBC1 expose of irresponsible lending practices at Lloyds TSB revealed how the high-street bank badgered a couple into taking on [pounds sterling] 100,000 of debt, which they could ill afford to repay. The man was unemployed and mentally ill. The woman was a low-paid, part-time nursing home assistant.             Hosking continued to criticize Lloyds and other banks that treading on dangerous ground in offering staff incentives. Many products such as pensions, life assurance and payment protection insurance do not sell themselves. “They have to be pushed actively.” However, Hosking reiterated the danger of subscribing into such operations. Such merchandising shift scheme resulted to its forceful pay out of 100 million pounds sterling in fines and compensation for mis-selling high-yield bonds. Hence, rethinking of proper methodical systems which both beneficial to clients and banks’ growth should be reviewed and constantly reassess or reevaluate.             Now, let us understand the whole issue on the global perspective in which the real strength of the bank is its ability to put together innovative customized solutions to strategic problems. Such solutions are based on an intimate knowledge of the client and long-standing trust on both sides. Hence, it is innovation, expertise, and relationships which differentiate banks from their competitors.   C. Consumer Behavior              (2002) provided new forms of distribution in financial services in response to emerging behavior of consumers. He rationalized that financial sector is undergoing a process of radical transformation as a result of increasing competition and changes in the purchasing habits of customers.             There is also a shift in perception by customers of the products and services offered and the value they place on them. For example, customers are much more focused on the type of account and service that they want and how they use it. This trend has been targeted by building societies offering current or cheque accounts and various levels of access to funds, thereby increasing the pressure on banks (p. 8).             In this environment the development of new distribution channels has become a key strategy in improving value added and satisfying customer requirements.             Customers’ behavior towards new ways of banking transactions and processes are varied and differentiated to some extent. The due reason for this is the fact that individuals perceive changes in different perspectives and treat new technological advancement as not a matter of choice but a necessity. For financial institutions such technologies as direct deposit, automated teller machines and debit cards can speed processing and reduce costs. Other services such as computer banking and store-value payroll cards are viewed as ways to retain existing customers and attract unbanked and underbanked consumers (, 2003).             There are direct observable influences which affect the behavior of consumers directly link to banking. Even in various areas of business operations, consumers manifest different behaviors depending on the products being promoted and serviced. In banking behavior some notable influences can be incurred as vital in understanding consumers’ behavioral accent. The demographic, economic, marketing-mix and situational factors are direct observable influences that can be determined in banking behavior of consumers. Moreover, there are inferred influences which affect consumers’ behavior. The internal and external influences varied accordingly. In human behavior system, the internal influences can be attributed to perception towards the products and services offer, motivation, lifestyle view, personality, learning process and attitude. The external influences are family, affiliation/reference group, social class, culture and sub-culture.             Hence, since human behavior towards products appreciation are varied and differentiated accordingly, we can incur that concrete identification of specific behavior towards banking and finance services are blurring due to variance of reactions of individuals. Moreover, the inferential and observable influences are clear yet, as to the specifications of consumers’ behavior towards appreciation on products and services provided by banking and finance institutions cannot be outline one by one. D. Marketing-Mix             It is not an easy task to identify areas of marketing in which we can make have a strategic implementation of programs in order to bring back returns and turnovers. The drawbacks in the banking and finance operations are not interjections of a single or homogenous body of currents, but are interrelated fields, heterogeneous in nature, which affect the whole stream of banking and financing process. In this sense, what we can provide is more or less a theoretical recommendation as a medication for drawbacks in banking and finance operations in the UK.             The drawbacks of finance and banking system in UK can be medicated through a strenuous yet positively and effectively help streamline finance strategies and banking operations. The proper evaluation of current trends, policies concerning banking and finance operations, government’s seriousness to design adoptable and friendly laws and regulations, and proper positioning and using of strategies. These factors can be considered relevant to the marketing-mix of banking process. The use of proper instruments and channels in order to promote and advance the programs of banking and finance are imperative. The economic robustness of certain business entity can be attributed to the effective use of media as channels of promotion. Whatever kind of media instruments can effectively develop and promote programs. Such relevance in the present scenario considered as vital yet crucial.             Hence, marketing-mix of UK’s banking and finance institutions should reconsider the utilization of various media instruments to further advance and promote its programs to consumers. It is very important that consumers enable to re-appreciate the worth of banking in their endeavors. Although, technology provides efficient service and easy way of transactions, still, the need of making consumers’ behaviors friendly to the services and products offerings of banking and finance programs are exceptional. Conclusion             This paper seeks to analyze the prevailing problem occurring in the banking and finance institutions in United Kingdom. By allowing ourselves to immerse in important points like understanding the financial market, banking systems and marketing-mix, we enabled to concoct clear analysis on the issue regarding the external and internal environment of the banking and finance industries of UK.             Moreover, employing different methodologies to analysis these issues like   five forces and the       analysis, we able to understand the deep-seated problems on financial institutions and banking system in United Kingdom. Thus issued certain suggestions and recommendations to amend and medicate the prevailing concerns.             Henceforth, we come to identify vital causes which affect the banking and finance landscape of United Kingdom. The emergence of new technology, global innovation and new strategic modes brought the attention of managers, analysts, experts and theorists to analyze the internalities and externalities environment of organizations or institutions in which can able to respond and adjust itself to these concurrent trends.   References:                                                               Credit:ivythesis.typepad.com

MARKETING: BANKING AND FINANCE IN UNITED KINGDOM

Banking and Finance in United Kingdom Introduction The omnipresence of global trends and innovations debunk the idea o...

DELIVERY OF CARE TO CANCER PATIENT

Abstract             In today’s world, the military physicians continually deploy, leaving their patients’ without a primary provider and making it difficult for them to practice continuity of care.  This is especially true in the case of cancer treatment.             As the seriousness of the disease grows, the importance of continuity also increases.  Unfortunately, the  (2003) review, found cancer care in the United States fragmented and without coordination.  The results of this study have shown a moderate level of continuity for Irwin Army Community Hospital’s (IACH) cancer population, specifically for the breast cancer patients.  While the hospital should be pleased with this finding, it still needs to improve its level of continuity. One approach to emphasizing continuity of care is to evaluate it periodically.  If continuity is important, then how it is measured is also significant.              The study begins by attempting to compare, analyze, and recommend the most stable model to measure continuity. The objectives for conducting this study are as follows: first, to determine if the delivery of care of Irwin Army Community Hospital (IACH) provides optimal continuity of care; second, to determine which variables influence continuity of care; and third, to determine which variables isolate those patients in the greatest need of continuity.              The findings of the study expect to demonstrate that the current process for continuity might be fragmented and inefficient because the hospital’s main priority is supporting the active duty population.  At times, this, and the fact that the hospital is short of physicians, influences the staff’s ability to see the other beneficiaries.                                TABLE OF CONTENTS INTRODUCTION…………………………………………………………………..……3             Conditions which prompted the study………………………………..………13             Statement of the management question.……………………………………14             Literature Review………………………………………………………………15             Purpose…………………………………………………………………………27             Hypothesis………………………………………………………………………27 METHODS AND PROCEDURES…………………………..……………………………28             Subjects and Events……..……………………………………………………28             Study Design…..……………………………………………………………….30             Data Analysis……..……………………………………………………………31             Results…….……………………………………………………………………33             Limitations………………………………………………………………………37                        Ethical Considerations…………………………………………………………37 DISCUSSION AND CONCLUSIONS…………..……………………………………39 LIST OF REFERENCES………………………………………………………………43 APPENDICES….………………………………………………………………………49             Appendix A……………………………………………………………………..49             Appendix B………………………………………………….………………….50             Appendix C……………………………………………………………………..51             Appendix D……………………………………………………………………..53             Table 1………………………………………………………………………….54             Table 2………………………………………………………………………….55             Table 3………………………………………………………………………….56             Table 4………………………………………………………………………….57             Table 5………………………………………………………………………….58             Table 6………………………………………………………………………….59   Introduction             For the year 2000, those who died of cancer represented 23% of all deaths in the United States ( 2001).  The top ten cancer types vary for men, women, and children, but the chances for developing cancer are high in all groups ( 2003).  In addition, as the population of older Americans increases, the number of people with a cancer diagnosis will double, increasing the demand for resources.  As this disease’s population growth continues, the strain on consumption (treatments for cancer, control medications) will continue to rise (, 2003).            (2001) reported several barriers to quality care for cancer patients.  These barriers include adequate cancer training for providers, poor management of cancer-related symptoms and lack of timely referrals.  Additionally, untold numbers of patients did not receive appropriate medical care because their geographical location was not conducive to receiving treatment. (, 2001).              These conditions resulted in the loss of public confidence in the system.  The National Cancer Policy Board (NCPB) responded by doing a review of the effectiveness of cancer services.  They found an “ad hoc and fragmented cancer care system that did not ensure access to care, lacks coordination, and is inefficient in its use of resources” (, 2003).  This prompted Irwin Army Community Hospital (IACH) to investigate continuity of care for their cancer patients as a way of improving patient treatment.               Continuity of care, specifically for cancer patients, in military health care has been included in many efforts of improving treatment.  It is one of the benefits reaped from the establishment of an Internet Tumor Board, a telemedicine system that is web-based to allow medical specialists to coordinate the care of cancer patients in the Asia-Pacific area.  The group that established this system had trouble with their patients being sent from one location to another, referring patients to the center facility for major treatments then handing them back to the local hospitals for continued treatment. Using this, they were able to eliminate potential for discontinuity that came from the transfers, and even from the frequent transfers of the military doctors themselves. (, 2000) This, and other researches and projects brought through agencies such as the U.S. Army Breast Cancer Research Program have sought ways in which treatment and care can be improved.             This then is an important component in providing quality patient care.  Research in continuity of care suggests a strong correlation between higher continuity and improved patient satisfaction.  Better continuity is associated with fewer hospitalizations, improved compliance, and lower emergency room use (, 2001).  Unfortunately, recent statistics reveal cancer patients are not receiving the best care due to inconsistent continuity (i.e. receiving care from multiple physicians).             The first step in this task began with settling on a definition of continuity.    (2001), article, aptly defined continuity in the context of quality health care as “good to the extent it increases likelihood of desired health outcomes and consistent with current professional knowledge while also providing patients with appropriate services in a technically competent manner, good communication, shared decision-making and cultural sensitivity” (p. 6).              (1980) defined continuity as: An uninterrupted succession of events or the existence of a mechanism to bridge parts to an event.  In medical terms, the successions of events are episodes of an illness, and continuity is the means to bring the episodes together to evaluate the illness.  (p. 123)             With these definitions, we see that the primary intent of continuity is to improve follow–up of patient’s problems and facilitate efficiency in diagnostic workup and management.  The information about the plan of care passes from one visit to the next (, 1980).  Continuity of care is dependent on provider consistency, or involvement with a limited number of consistently available providers aware of the patient’s medical history. Thus the components of continuity include: ·         Medical care consistent with current knowledge ·         Competency ·         Appropriate services ·         Mechanism that brings multiple episodes of treatment together to evaluate the illness ·         Good communication ·         Shared decision making ·         Cultural sensitivity             Using these components of continuity of care, the researcher will explore the scope of cancer services provided by IACH providers.  This will include a review of the standards of practice accreditations that ensure quality cancer care, such as putting emphasis on the reliability of test data results which gives research its merit.             Currently though, IACH has earned the American College of Surgeons (ACoS) Commission on Cancer (CoC) accreditation in the Hospital Associate Cancer Program category.  This means on site services are limited but are available by referral (See Appendix A).  According to  (2003) this also means that IACH’s cancer patients will receive: ·         Quality of care close to home. ·         Comprehensive care offering a range of state of the art services and equipment. ·         Multi-specialty, team approach to coordinate the best cancer treatment options available. ·         Access to cancer related information, education, and support. ·         A cancer registry that collects data on cancer type, stage, and treatment results and offers lifelong patient follow-up. ·         Information about clinical trials and new treatment options. (p. 2)                          In order to maintain accreditation, IACH must undergo an on-site review every three years, where continuity can be measured alongside the listed factors. To examine continuity of care in a given patient population, tools such as the Modified Continuity Index (MMCI) and others can be used.                           Continuity of care is a necessary part of the health care process; it leaves a positive impression on patients, and increases satisfaction.  With increased satisfaction, beneficiaries will continue to use the facility for their entire health Care needs.  But as military health care moves to the Next Generation of TRICARE contract, a military facility unable to provide a modern standard of care or deliver a perceived quality of care, equal to that provided in the civilian community may experience a loss of enrolled members (, 2000).               Conditions Which Prompted the Study              IACH underwent a re-organization to the military’s health plan TRICARE in 1988.  This resulted in the closure of the Department of Medicine.  IACH no longer had the capability or the staff to see other than active duty soldiers and dependents within their catchment area (See Appendix B).  All retirees and their families felt the impact of these decisions in 1998. By the end of 2000, this affected the cancer patients, forcing many to find a physician in the private sector.  Unfortunately, some of these patients did not find another provider.  According to , (March 15, 2004), the Tumor Registrar at IACH, “It is this group and even some of those with outside providers that show up multiple times in IACH’s emergency room (ER) when they are very sick.”  This leaves a group of beneficiaries without a central source of care.              In October 2004, TRICARE, the military health plan, will transition to the Next Generation of TRICARE contract although the basic benefit structure (TRICARE Prime, Extra, Standard, and Plus) will remain unchanged.  Some of the benefit plan responsibilities will transfer from the TRICARE contractor to the military treatment facility (MTF) Commander.  This change provides incentives for the MTF to adopt best practices, provide measurable performance in customer service, quality of care, and access to care (, 2003).              The MTF, funded on historical data, will also receive the revenue paid in the past to the contractor.  The MTF will then pay the contractor for the services Prime enrolled beneficiaries receive in the network.  This provides the MTF with the flexibility to determine whether to provide in-house or network services based on cost effectiveness and the need of beneficiaries in the area.             Currently, IACH provides health Care services to a population of over 32,968 with a budget of .6 million for the 2002 fiscal year.  IACH authorized staff comprises 266 military, 360 civilians, and multiple contract personnel. The shortage of providers described here is incremented by IACH’s support on the war on terrorism by the deployment of their medical staff.             IACH is consciously aware that the shortage of physicians, inability to see all enrolled beneficiaries, and the changes in the TRICARE contract affects continuity of care.  A review of the current researches conducted in this field has shown that there are few who focus on the topic of continuity in this context. Rather, like those that are included under the Department of Defense’s Congressionally Directed Medical Research Programs, most of them only list continuity under the benefit of primary care improvement, or a requirement of it.             This study will help IACH measure the continuity of care for their breast cancer patients under these considerations.  Additionally, it should help determine the details of the factors that impact continuity of medical care.   Statement of the Management Question             This study will attempt to answer the questions identified from the literature associated with continuity of care and then apply them to the cancer patients at IACH. In particular, the researcher seeks to reply to the following questions: Research Question 1:  Do IACH providers offer continuity of care to their breast cancer patients?  Research Question 2: To what extent do outpatient visits, readmissions, and ER visits predict MMCI scores? Research Question 3:  Are there any relationships between MMCI scores with age, gender, race, beneficiary status and length of disease?  Research Question 4:  Do the participants’ MMCI scores differ by stage and site of cancer?         Literature Review             To evaluate the study methods and measurement techniques which have been employed in the study of continuity of care, ’s includes those that used age at diagnosis, gender, and length of the relationship and stage of cancer as variables that might influence continuity of care.  These were used to answer the question of the relationship between continuity and emergency room (ER) visits and those between cancer type/stage and frequency of visits. But all of these studies do not agree on the definition and role of continuity. (pp. 1-19) So from this we see that the study of continuity involves visiting patterns and concentration of providers             On the other hand,  (1994) felt that “continuity of care is established when a patient’s physician is able to understand interrelationships” (p. 14).  In other words, the patient’s feelings, past medical history, signs, symptoms, treatments, and responses to the treatments all need to be included to define or understand continuity of care.             Unfortunately, delivery of care to cancer patients is usually complex and uncoordinated, resulting in patient handoffs that delay care and decrease the quality of care over the continuum.  In turn, these developments are associated with bad health outcomes or even death (, 1999).              Regarding this,  (1975) proposed that “there are certain medical conditions that need a higher degree of continuity.  For example, a patient will require additional follow-up appointments when there is a chronic problem than an injury requiring sutures.  The age of the population may also be important, as older age groups tend to have more severe long-term health problems.  The high mobility of the American population may render the goal of continuity unattainable.” (p. 141)                The importance of continuity of care increases with the seriousness of the condition.  When a lack of continuity occurs, it is disruptive and stressful for the patient with chronic conditions.  Patients perceive they receive better care if they have continuity, creating a higher level of trust (, 2002).  When seen by their regular physician, patient satisfaction increases with physician performance ( 1996).  Positive patient-provider relationships have shown to affect certain health behaviors such as lowering emergency room visits and even hospitalizations ( 2001).  Long-standing physician-patient ties foster less expensive and less intensive medical care (, 1996).             Efforts to improve continuity may improve the quality and outcomes of care ( 2001).   (2003) found in their literature review that “greater continuity is associated with reductions in hospitalizations, improvement in follow-up, increase in patient satisfaction, promotion of compliance with recommended care, and a reduction in duplication of tests” (p.992).               (2004), in their literature search, also found evidence that “continuity of care is associated with a decreased likelihood of future hospitalizations and less ER use” (p. 36).               (1975) proposed that continuity is a must for patients with chronic problems.   (2002) suggested the importance of continuity increases with the seriousness of the condition.  Other studies demonstrate that continuity decreases duplication of tests, ER visits, hospitalizations, which decrease the cost of care.  This information substantiated the value to further investigate continuity of care.  It thus became important to discover how other continuity studies’ formulated their research design.  Unfortunately, there is not any continuity of care research from military facilities to use as a model.              The following three studies either helps define variables, narrow definitions; show categorizing within a variable or present design possibility for this research.             First,  (1987) started by defining measures of continuity as: the relationship between a patient and his or her primary provider and the generation of a meaningful numerical value that is easily understood.  They collected data for 201 patients.  The patients included made 1,154 visits to physicians over a two-year period. Fifty-nine percent were female; the average age was 28 with a range 1 year to 80, sixty-five percent had an assigned provider and twenty-six percent of the patients had all encounters with the same physician.  The result section included a COC, MCI, and MMCI scores for each patient (Appendix C). The findings substantiate that the use of UPC calculated scores of more than twice those calculated for COC.  The COC is sensitive to number of physicians seen and the MCI is results that may mislead users ( 1987).              Second, a study by  (2003) collected data on deceased cancer patients (8,702) with a confirmed pathological cancer report.  They limited their research to office visits for the last 180 days of the subjects’ life.  The MMCI measured continuity of care as an independent variable and ER visits (total count of ER visits during each patient’s survival time) as the dependent variable.              They used descriptive statistics, followed by negative binomial regression analysis with adjustments for varying survival times to assess the association between continuity and the total number of ER visits.  Then variables associated with ER use in the bivariate analysis at a 0.1 level of significance and associated with continuity were included in the multivariate regression, along with the demographic variables (e.g., sex by age, sex by cancer death).              Finally, their subsequent modeling employed manual backward elimination to develop the final model of total emergency room use and association of provider continuity of care.  The skewed distribution of their continuity scores forced them to categorize continuity as being low (scores < 0.5), medium (scores 0.5 to < 0.8), and high (scores 0.8 and greater).              The majority of their patients were 65 years of age or older (72%), female (45.1%), male (54.9%), the most common cancer was lung (26%) followed by breast (10.2%), prostrate (9.2 %), colorectal (8.5%) and all others (53.1%).  The continuity scores ranges included low (0.02-0.47, (8.1%)), moderate (0.50-0.79, (35.6%)) and high (0.80-1.00, (56.4 %)), ( 2003).             And the third under the group of studies we’ve been following is by  (2000), and was concerned with the effect of continuity of care on ER use.  It is of importance because it compares UPC and MMCI scores but also provides examples of definitions for variables, narrows the definition of visits, categorizing within a variable when needed and uses ER visits as a dependent variable.              Their analysis was performed by using the MMCI index as their main continuity measure.  However, since the UPC index is commonly used, they ran an additional analysis in place of the MMCI.  They defined visits as office or clinic visits to a physician, nurse practitioner, or a physician assistant.  They excluded ER visits because it was their dependent variable.  Additionally, they excluded special procedures and visits to other providers such as chiropractors, optometrists, and psychologists.  They categorized each patient’s ER visits into three levels (no ED visit, 1 ED visit or multiple visits).  This categorization allowed them to measure the effect of a single ER visit to multiple visits in the same model.  They did not examine ER visits as a continuous variable because of the extreme bias and kurtosis of the data violated the assumptions for linear regression.              In their main analysis, they measured the association between MMCI and ED visits by using a polychromatous logistic regression, with a 3-level categorization (no ER visit, 1 ER visit or multiple visits) of ED visits as the dependent variable.  They used a categorical data model because the different levels of the predictors did not meet the assumption of proportionality of odds.  They first ran the model with only continuity as the predictor variable.  They then ran the model after controlling for the number of office visits during the study.              Their previous analysis showed the number of office visits to be a strong negative confounder of the association between continuity and hospital use (i.e., office visits are positively associated with the dependent variable but negatively associated to the independent variable, so this would result in an apparent negative association between the independent and dependent variables.  They then ran the model with continuity and all control variables forced into the model to determine the effect of continuity.              Finally, they ran the model using a stepwise technique, to determine the best predictor model.  For the stepwise technique, they included predictors associated with ED visits from the univariate analysis with a P < .25 or the variables considered clinically relevant.  Stepwise selection showed P < .05.  They then added variables back to the model if they changed the co-efficient of the other variables by more than 15%.  The final model showed good predictor accuracy (c=0.81).  (pp. 334-335)             The preceding sections of this literature review establishes that continuity of care results in better health outcomes, helps coordinate care, increases trust, and reduces hospitalizations. Provider and emergency room visits also decrease which in turn lowers health care costs.  This prompted the researcher of this study to evaluate the best measurement for continuity of care.             The  (1987), “study considered three models used in the past to measure continuity of care.  They found each of these continuity indexes did not truly represent the relationship of total number of visits to the total number of providers” (p.167).  Building on strengths of each measurement, the authors developed a new model that truly represents the total number of patient visits to the total number of providers.                The author explored measure to determine which is best suited to use in this research. The first measure, usual provider of care (UPC), oversimplifies the relationship between patient and provider.  UPC is simply a ratio, determined by limiting the visits to highest number of visits to one provider divided by the total number of providers.  The UPC produces a measure that ranges from zero to one.  The zero represents all visits to different providers and one represents all visits to the one provider.             UPC = V/Pr                                     (1)   V = Total number of Visits Pr = Total number of Providers             For example, if a patient has eight visits, (four visits to one physician and four visits to four other providers), the calculated UPC is 0.8 (4/5).  The problem with the UPC concept is that it does not accurately account for the total number of visits.   (1980) and  (2003) have substantiated in their research that the UPC does not emphasize the number of different doctors seen.                         The second measure they examined was continuity of care (COC).   [(Pr)2 + (Pr)2 + (Pr)2 + (Pr)2  + (Pr)2)-V]             (2)                       [V (V-1)]                        V = Total number of visits Pr = Numbers of visits to provider             This formula attempts to account for visits to individual physicians.  For example, if a patient has a total of eight visits, four visits to a specific physician and the remaining four, each to different providers, COC would be 0.214 while the UPC would be 0.8.  The COC also produces a measure that ranges from zero to one.  The zero represents all visits to different providers and one represents all visits to the one provider.             The UPC does not accurately account for total number of visits.  Additionally, it falls rapidly with a large number of providers.             The third measure is the modified continuity index (MCI), which tries to provide sensitivity to the total number of visits and providers (1984).  The formula for MCI is as follows:   MCI=1-(Pr of providers / [V of visits + 0.1])                       (3) V = Total number of visits Pr = Numbers of visits to provider             This measure also generates a continuity score of zero to one.  The zero represents all visits to different providers and one represents all visits to the one provider.  Again, using a patient with eight visits, four visits to the same provider and the  remaining four to four different providers; UPC=0.8, COC=0.214 and the MCI=0.38.  While the MCI is less sensitive and less misleading, it still does not truly reflect the relationship to the total number of providers to the total number of visits.              The shortcomings of previous measures for continuity prompted  (1987) to develop a new more meaningful measure, the MMCI.  This measurement tool is derived from the modified continuity index.  The MMCI produces a measure that will also range from zero to one.  The zero represents all visits to different providers and one represents all visits to the one provider.              The formula is as follows:   MMCI = 1-(Pr / [V  0.1])                      (4)                  1-(1 /[V + 0.1]) V = Total number of visits Pr = Numbers of visits to providers                       Again, using a patient with eight visits, four visits to the same provider and the remaining four to four different providers; the UPC = 0.8, COC=0.214, MCI=0.38 and the MMCI of 0.44.  The MMCI measure is not overly sensitive to the large number of providers and allows intuitive interpretation of continuity regardless of number of providers.             Before deciding to use a measurement, it is important to check the instrument’s validity or the extent to which a test measures what it purports to measure.  If a patient has two visits to two different providers (See Appendix C, row 2), the resulting MMCI is 0.10.   If you compare the results of the other measures UPC=0.50, COC=0.00, MCI=0.05 to the MMCI, it becomes clear that the MMCI is less misleading.  It also accurately represents a small number of visits.  This also establishes the preciseness of the index, which is one of the components of reliability.             Appendix C (Row 4) also demonstrates the value and validity of the MMCI.  If a patient has a total of three visits, two visits to one provider and one to a different provider, the score of the MMCI=0.51, UPC=0.67, COC 0.33, and the MCI=0.35.  The MMCI comes the closest to truly representing the total number of visits to total number of providers.  The COC and MCI scores give the impression of very low continuity and the UPC is misleading.             Reviewing the previous sections, this study then used the MMCI.              On that note, this study will employ the Modified Continuity Index (MMCI) to examine continuity of care in this patient population.  The researcher feels that previous measurement tools did not accurately represent the connection between the number of providers seen and total number of visits. The MMCI is the most consistent true measure and the most predominant model currently found in the literature.  It accounts for the degrees of dispersion among different providers.  Continuity for this study is a MMCI .51 or greater.                              Purpose                                                        This study was conducted with the following three objectives in mind. First, it will determine if the delivery of care for cancer patients at IACH provides optimal continuity of care.             Second, to determine which variables influence the continuity of care.  And third, to determine which variables isolate those patients in the greatest need of continuity of care.              The findings will demonstrate that the current process for continuity of care may be fragmented and inefficient.  This is because IACH’s main priority is supporting the active duty population.  At times, this influences the staff’s ability to see other patients.  Also the hospital and the military are below strength in number of physicians.  Lastly, patients often opt to see the first available provider instead of waiting for their assigned physician.   Hypothesis H0: The current process for care of breast cancer patients at IACH provides continuity of care.  H1: The current process of care for breast cancer patients at IACH does not provide continuity care.     Methods and Procedures             The purpose of this section is to review the description of the participants in this archival study, present the measures and procedures used to collect the data, and discuss the proposed treatment of the data.   Subjects and Events             The majority of IACH’s beneficiary population resides within the Fort Riley, Manhattan and Junction City zip codes.  The use of the ACTUR database limited the participants to this area.  For inclusion in the research, each subject was an IACH beneficiary at time of the initial cancer diagnosis.  Additionally, patients must have had at least four outpatient visits.  The consensus of research related to continuity of care, supports the inclusion of patients with four or more visits.             IACH cancer patients’ data came from ACTUR database, the Composite Health Care System (CHCS), (for services within IACH) and the Military Health Services Management and Analysis Reporting Tool (M2), (for services outside IACH).  This study selected only specific data related to patients with the diagnosis of cancer.  Appointments for tests (X-ray, MRI, CT, labs) or treatments (chemotherapy) were not included.              The data collection included: diagnosis, date of diagnosis, age at diagnosis, stage of disease at diagnosis, and current documented “evidence” or “no evidence” of disease.  The demographic information included: beneficiary status (CHCS), age at diagnosis (ACTUR), gender (ACTUR), and race (ACTUR).  The Composite Health Care System and M2 provided hospitalizations (number of separate admissions), number of providers, visits to a physician and to the ER.  Each subject had a MMCI Index calculated.  The continuity measure indicates the degree of continuity from January 1995-February 2004.  The MMCI value is a measure ranging from zero to one.              For the purposes of this study, MMCI scores .51 and greater represented continuity.  Visits are defined as outpatient visits to a provider but do not include visits for testing (labs, diagnostics (x-ray, CT, MRI) or chemotherapy) nor does it include emergency room visits in the MMCI calculations.  A provider is defined as licensed medical doctor, nurse practitioner or a physician assistant.             The accuracy of the data collected is an important aspect of any study.  To ensure the data is consistent, accurate, and precise (reliability), the researcher and the tumor registrar,  reviewed it for accuracy.    Study Design             The review of past studies helped formulate the design for this research.  This is a retrospective study.  Irwin Army Community Hospital’s Tumor Registrar granted permission to use the ACTUR database to glean information for this analysis.              The ACTUR database provided cancer patients’ length of years with the diagnosis (continuous), staging (See Appendix D for coding), age at diagnosis and follow-up testing, and “evidence” (recorded as 1= no evidence of cancer and 2 = evidence of cancer).  The CHCS database provided beneficiary status (20=active duty/retirees, 30=all dependents), outpatient and ER visits, total number of providers, and IACH hospitalizations for each subject.  The Military Health Services Management and Analysis Reporting Tool (M2) database provided any appointments to outside providers and hospitalizations to other facilities.  The data went into one file.  With this merger, the influences on continuity emerged.     Data Analysis             SPSS 11.5 analyzed the data.  The use of descriptive analyses (i.e., summary statistics) of the variables helped determine their characteristics, estimate the proportion of participants that have those characteristics, discovered the associations among the different variables and measured cause and effect among the variables ( 2001).  Cause is defined as the variables that cause effects or influence continuity.  Descriptive statistics will analyzeed all subjects while regression was limited to the breast cancer types group with 4415 or more subjects.  This was the only group with 15 or more subjects.   (1996) found, for a reliable regression equation, 15 participants per predictor are needed” (p. 72). Research question 1:  Does IACH providers offer continuity of care to their cancer patients?              Each subject had a MMCI score calculated.  The definition for continuity of care is a MMCI score of .51 or greater.  The visits used to calculate the MMCI included visits both within IACH and outside the hospital from January 1995 thru February 2004.  The visits were limited to a licensed medical doctor, nurse practitioner or physician assistant.  The visits did not include treatments, diagnostic testing or therapy.  Both provider and visit data were checked and rechecked for accuracy by the researcher and the tumor registrar.  To answer this research question, the frequencies of the MMCI scores .51 or greater determined continuity of care.    Research question 2: To what extent do outpatient visits, readmissions, and ER visits predict MMCI scores?              A multiple regression examined the extent to which the independent variables of outpatient visits, readmissions, and ER visits predicted the dependent MMCI scores. The assumptions of regression included (multicollinearity (Some or all variables are highly correlated), linearity (the collection of data can be described as a straight line), and homoscedasticity (data evenly dispersed both above and below the regression line), (2001).   (1966) explain, “it is common in a multiple regression analysis to have a high degree of correlation between two or more explanatory variables (independent) that it is impossible to measure accurately their individual effects on the explained (dependent) variable” (p. 66).   Research question 3:  Are there relationships between MMCI scores with age (continuous), race (1=white, 2=other), gender, beneficiary status (20=active duty or retired, 30=dependents) and length of disease (continuous)?              “Evidence” and “no evidence” (determined by yearly follow-up testing) of cancer established any changes in severity of the diagnosis.  Specifically, the use of Pearson correlation coefficient (determines relationships between variables) and point-biserial correlations (dichotomous variables that represent a natural dichotomy such as evidence and no evidence) determined correlations for continuous and dichotomous variables, respectively.    Research question 4:  Do the participants’ MMCI scores differ by stage (See Appendix D: codes) of cancer?              The assumptions of ANOVA, normality (the normal distribution of the mean and the standard deviations) and equality of variance (measures the dispersion of the values determined by taking the square root of the variance) assessed the difference on MMCI scores by stage (See Appendix D).  Stage seven (distant metastases) was treated the same as other categories of stages.  The total number of outpatient visits, used in calculating MMCI, helps control for disease severity.  The outpatient visits help interpret the statistical relationship between the MMCI score and stage.  Results from other studies, show the total number of outpatient visits, is associated with severity of disease, increase in ER use, and hospitalizations.  Groups that exceed 5% (6) of the population of this study (118) will be used in the calculations (, 2001).     Results             One hundred and eighteen patients, 41 (34.7%) males and 77 (65.3%) females, were initially included in this study.  Eighty-eight (74.6%) were identified as Caucasian and 30 (25.4%) as “other.”  Of these patients, 42 (35.6%) had active duty or retired status, while 76 (64.4%) had dependents to include children.  The mean MMCI score for this group .59, which by definition signifies some continuity (continuity is >.51).  Table 1 presents the minimum, maximum, mean and standard deviations by age, years of cancer, number of visits, number of providers, ER visits, hospital days (HD), Total Providers (TP), Total visits (TV), MMCI and evidence of cancer.  Table 2 presents the frequency and percent of staging.             Of the initial sample, 44 women with breast cancer were examined to observe relationships among variables.  Thirty-four (77.3%) were identified as white and 10 (22.7%) as “other.”  Table 3 presents the minimum, maximum, mean and standard deviations by age, years of cancer, number of visits, number of providers, ER visits, HD, TP, TV, MMCI and evidence of cancer.  Table 4 presents the frequency and percent of staging.  In terms of evidence of cancer, 2 (4.5%) did have evidence while  42 (95.5%) were still cancer free.  The mean MMCI score for the breast patients was.58.    Research questions             The first research question examined if IACH provided continuity of care to their breast cancer patients.  Continuity of care was defined as an MMCI score at .51 or above; Table 3 shows that the mean MMCI score for breast cancer patients was .58 (SD=.22).  Therefore, continuity of care was given to these patients.              The second research question examined to what extent outpatient visits (OPV), readmissions (RA), and ER visits (ERV) predicted MMCI scores in breast cancer patients.  In terms of assumptions, standard scores were calculated for MMCI scores, and assessed for outliers, where there were none.  Multicollinearity was assessed with the variance inflation factor statistic (VIF).  VIF scores above 10.0 are problematic, and the VIF’s for the predictors were all below 2.0.  Linearity and constant variance were assessed by plotting the residuals verses the predicted values, where these assumptions were met.              The three predictors (OPV, RA, ERV), accounted for 17.1% of the variance in MMCI scores, and the model was marginally significant, F (3, 40) = 2.75, p = .055.  Table 5 shows that visits were a significant predictor of MMCI scores.              The third research question examined the relationships between MMCI score with age, race (Caucasian =1, other=2), years with cancer, and years seen.  Table 6 shows the correlation coefficients, where race and years with cancer were statistically significant with negative correlations.  The negative relationship with race indicates that “other” races tended to have higher MMCI scores than Caucasians.  The negative relationship of MMCI and years with cancer indicates that as years of cancer increases, MMCI scores decrease.              The fourth research question examined if differences existed in MMCI scores by stage (0 vs. 1 vs. 2/3).  Stages 2 and 3 were collapsed because there were too few (only 2) stage 2 patients.  The assumptions of normality were met, and Levene’s homogeneity of variance was non-significant.  The ANOVA was not statistically significant, F (2, 41) = .01, ns.  All three groups had similar MMCI scores: stage 0 (M=.57, SD=.15), stage 1 (M=.58, SD=.23), stage 2/3 (M=.59, SD=.23).    Limitations             First, this study is limited to cancer patients treated at IACH.  The results are only applicable to the cancer patients in this one small military facility.  The analysis only included those patients with four of more visits.  All persons with one visit would be classified as having a perfect MMCI score, which is not an accurate representation.              The small number of subjects in this study may not show associations that might be found in a larger study.  Additionally in some cases, the use of the categorical data optimized manageability but also sacrificed the details of that data.  On the other hand, this type of data forms solid scientific evidence.             After establishing facts with the categorical data with this study, subsequent studies, such as qualitative researches, can be done to describe and support the details of its findings.   Ethical Considerations             The ethical conduct of this study was extremely important to ensure that the benefits of conducting this research was not overshadowed inappropriate data collection or disclosures.  The identities of the cancer patients were kept confidential as in keeping with the guidelines stated within the  Report which follows the principles of (1) the respect for persons, (2) beneficence, and (3) justice. (, 2000)             According to the report, participants in a research must be treated as autonomous agents with the capability of deciding and making choices for themselves. The researcher is then accountable for participants with diminished autonomy, such as those with physical or mental incapacities. The participants should not come to any form of harm under the study, and the researcher should extend considerations for good outcome from the study to include the benefits to the participants themselves, science, and humanity.             Any participant should have voluntary informed consent to be in the study, and should have been informed of all procedures, purposes, and risks inherent therein, as well as being able of legal capacity to understand the information entailed by the research.   Discussion             As previously stated, the military health care setting is one of the more difficult settings in which to practice continuity.  In today’s world, the military physician faces being deployed, leaving their patients’ without a primary provider.  One approach to emphasizing continuity of care is to periodically evaluate it.  If continuity is important, then how it is measured is also significant.  The literature review substantiated the strengths of the MMCI.  But this study additionally demonstrated the strength of the MMCI to the other measurements in use.             The mean MMCI score for this study average was .59 and .58 for the breast patients.  For comparison, the study with terminally ill cancer patients found a mean MMCI score of 0.78.  This indicates that while this group has a moderate measure of continuity, there is room for improvement.              Not only is it important to measure continuity but to also discover the factors that impact it.  Once these are isolated then a plan can be in place to increase continuity.  The outpatient visits, readmissions and ER visits model for the breast cancer patients was only moderately significant.  But, the number of outpatient visits proved to be a significant predictor of the MMCI scores.  This is supported by the work of (YR) and  (YR).             While the ER visits and readmissions were not significantly predictive of MMCI in this research, other studies by  found ER visits are a predictor of MMCI scores.  Studies by  studies found the number of readmissions are also a predictor of MMCI scores.              Interestingly this study did find that races other than Caucasians had higher MMCI scores.  This result has not been reported in any of the other studies.              Research by  has found as the years of cancer increase, the MMCI scores decrease. The findings of this study further support this literature.             Studies by  suggested that patients with chronic diseases require a higher degree of continuity.  In this research, MMCI scores did not show a difference by stage.  This is similar to the  study where there was no significant association between continuity of care and stage of cancer at diagnosis.              The results of this study have shown a moderate level of continuity for IACH’s cancer population and specifically the breast cancer patients.  The literature review established the importance of continuity increases with the seriousness of the disease.  Unfortunately,  2003 review, found cancer care fragmented and without coordination.  Irwin Army Community Hospital might be able to increase the level of continuity with additional health care providers.  However, this option is not likely to occur.  Priorities demand providers fulfill their main mission, which is to deploy with the soldiers, ensure the medical fitness of troops that mobilize and demobilize, and care for the injured soldiers returning from the war in Iraq.  An alternative is substituting case managers to follow the cancer patient population.  They coordinate care and follow up with patients.   (1998) wrote “case management is a primary means to provide continuity of care across multiple institutions and practitioners” (p. 151).  While not the best answer, it might maximize continuity.  Another option is to refer patients to the local referral facilities.  Unfortunately, they also have capacity limits.  According to  (2004), not only is the state of Kansas short of health care providers but also has difficulty in recruiting them.              We are not the only military health Care facility facing lack of continuity of care for enrolled beneficiaries.  Given the impact and the increasing number of cancer patients, the leadership within the United States Army Medical Command would find the results of this study useful.  The MMCI model provides a measure to determine continuity of care.  The moderate continuity findings, suggest a need to improve continuity of care.  This will not only help the patient, but also reduce health care costs.  Ultimately, the leadership, soldiers, family members, and retirees within the greater Fort Riley community will benefit from the results of this study.              This concept will help revise the management of continuity of care for all patients.  It would further increase IACH’s reputation as providing efficient, effective, and quality health Care, while decreasing costs with a decrease in hospitalizations and emergency room visits.                 References   Appendix A   (, 2000)   <p style="line-height: 200%; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; font-size: 12.0pt; font-family: Arial; color: windowtext; font-weight: bold; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt"> The star is the location of Irwin Army Community Hospital.  The arrows designate referral facilities used by IACH.  This allows the beneficiary population to receive the full spectrum of medical care. <p style="line-height: 200%; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; font-size: 12.0pt; font-family: Arial; color: windowtext; font-weight: bold; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt">     <p align="center" style="text-align: center; line-height: 200%; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; font-size: 12.0pt; font-family: Arial; color: windowtext; font-weight: bold; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt"> Appendix B <p style="line-height: 200%; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; font-size: 12.0pt; font-family: Arial; color: windowtext; font-weight: bold; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt">   <p align="center" style="text-align: center; line-height: 200%; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; font-size: 12.0pt; font-family: Arial; color: windowtext; font-weight: bold; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt"> (, 2000) <p style="line-height: 200%; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; font-size: 12.0pt; font-family: Arial; color: windowtext; font-weight: bold; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt">   <p style="line-height: 200%; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; font-size: 12.0pt; font-family: Arial; color: windowtext; font-weight: bold; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt"> The star represents the location of Irwin Army Community Hospital.  The majority of beneficiaries of the medical facility live within the oblong shape.           <p align="center" style="text-align: center; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; line-height: 200%; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt"> Appendix C <p align="center" style="text-align: center; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; line-height: 200%; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt">   <p align="center" style="text-align: center; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; line-height: 200%; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt"> Comparisons of Continuity Scores <p align="center" style="text-align: center; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; line-height: 200%; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt">   Components of Continuity Formulas and Score Comparison Pr <p align="center" style="text-align: center; line-height: 200%; punctuation-wrap: simple; text-autospace: none; vertical-align: baseline; margin-left: 0in; margin-right: 0in; margin-top: 0in; margin-bottom: .0001pt"> V DV UPC COC MCI MMCI 1      2 2 1.00 1.00 0.52 1.00 2 2 1,1 0.50 0.00 0.05 0.10 1 3 3 1.00 1.00 0.68 1.00 2 3 2,1 0.67 0.33 0.35 0.51 3 3 1,1,1 0.33 0.00 0.03 0.04 1 4 4 1.00 1.00 0.76 1.00 2 4 3,1 0.75 0.50 0.51 0.67 2 4 2,2 0.50 0.33 0.51 0.67 3 4 2,1,1 0.50 0.17 0.27 0.36 4 4 1,1,1,1 0.25 0.00 0.02 0.03 1 5 5 1.00 1.00 0.80 1.00 2 5 4,1 0.80 0.60 0.61 0.76 2 5 3,2 0.60 0.40 0.61 0.76 3 5 3,1,1 0.60 0.30 0.41 0.51 3 5 2,2,1 0.40 0.20 0.41 0.51 4 5 2,1,1,1 0.60 0.10 0.22 0.28 5 5 1,1,1,1,1 0.20 0.00 0.02 0.03   Appendix D Staging and Code Numbers for Cancer Staging of Cancer   Table 1   Minimum, Maximum, Mean and Standard Deviations by Age, Years of Cancer, Number of Visits, Number of Providers, ER Visits, HD, TP, TV, MMCI And Evidence of Cancer    Variable Min Max M SD Age 7 87 52.58 15.08 Yrs cancer 1 34 7.99 6.41 Visits 4 176 23.04 21.66 Provider 1 65 9.52 8.86 Years seen 0 10 4.14 2.16 ER visits 0 230 3.87 21.24 Hospital 0 4 0.48 0.84 HD 1 30 5.68 6.60 TP 1 65       9.16   7.65 TV 4 176 22.97 21.27 MMCI 0 1 0.59 0.21 Evid Canc. 1 2        1.14 0.34                                                                                         Table 2 Frequency and Percent of Staging   Staging  Freq   Percent   0 15 12.7   1 59 50.0   2 10  8.5   3 18 15.3   4  4  3.4   5  1  0.8   6  0  0.0   7 11  9.3 Note. n=118. Table 3   Minimum, Maximum, Mean And Standard Deviations By Age, Number Of Visits, Number Of Providers, Years Of Cancer, Years Seen, ER Visits, Number Of Hospitalizations, Number Of Day In Hospital, and MMCI   Variable Min Max M SD Age 31 72     53.39 9.66 Visits 6 69     24.30   17.74 Provider 1 28 9.70 6.25 Years Cancer 1 24 9.07 6.24 Years seen 0 8 4.09 1.93 ER visits 0 13 2.16 3.21 Hospital 0 4 0.48 0.85 Days 0 10 1.41 2.81 MMCI 0.12 1 0.58 0.22                                                                     Table 4                         Frequency and Percent of Staging   Stage Freq Percent 0 5 11.4 1 27 61.4 2 2 4.5 3 10 22.7                     Note. n=44       Table 5 Regression: B, Standard Error, Beta Weights, t, and Significance Levels for Variables and MMCI scores as the Criterion   Variables B SE Beta t Sig. Out. Visits .004 .002 .361 2.431 .020 ER Visit -.019 .010 -.276 -1.861 .070 Hospital .014 .037 .053 .367 .716     Table 6   Correlation for MMCI scores with Age, Race, Years with Cancer, and Years Seen     MMCI Age .09 Race -.32* Years cancer -.40** Years seen -.03   Note.  n=44, race (Caucasian=1, other=2), *p < .05, **p < 01.      </div> Credit:ivythesis.typepad.com

DELIVERY OF CARE TO CANCER PATIENT

Abstract In today’s world, the military physicians continually deploy, leaving their patients’ without a primary provide...