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While demographic changes in future decades should expand the need for subspecialists in reconstructive pelvic surgery and urogynecology, managed care will probably limit access of patients to specialists in this field. Much of the evaluation and treatment for women with prolapse and incontinence will be provided by primary care providers.
In 1981 a nationwide effort to control high blood pressure was implemented. One of the first programs was the "Hypertension Control Program of the Negev." The program's major objective was to introduce early detection and improve diagnostic, treatment, and follow-up procedures to 27 primary-care clinics of the area. The evaluation was based on the program's three levels of intervention: (a) basic training program and written protocol, containing guidelines for diagnosis, treatment, and follow-up; (b) additional consultation in the primary-care clinics by internal medicine specialists from the regional medical center, and (c) additional consultation in the primary-care clinics by the hypertension unit's medical team. In 1981 (prior to any intervention) a random sample of 5,717 medical records of the target population (30 years or older) was reviewed. High blood pressure was found in 1,032 patients (18%); however, a written diagnosis of hypertension was recorded in only 57% of these cases, and of these only 37% were being regularly treated for high blood pressure. In 1983, a second, independent random sample of 7,791 records was reviewed. High blood pressure was again found in 18% (1,428) of the cases, but 69% of these had a recorded high blood pressure diagnosis (a relative increase of 21% from 1981), and 85% of these were treated for high blood pressure (a relative increase of 130%). Improved performance in the steps of care provided for high blood pressure was observed in all the clinics. Surprisingly, the percentage of well-controlled patients increased only in those clinics where the staff gave consultation services.(ABSTRACT TRUNCATED AT 250 WORDS)
Bariatric surgery is an appropriate intervention for the treatment of morbid obesity. Using the National Association of Clinical Nurse Specialist's "spheres of influence" model, the clinical nurse specialist (CNS) is able to lead in the development and maintenance of an effective hospital-based bariatric program. The three spheres include the patient/client, the nurse/nursing practice, and the organization. The CNS is vital in guiding the education and support for patients and hospital staff. S/he is also instrumental as a leader in developing an environment that is conducive to supporting the bariatric patient population. By employing the three spheres in the program, everyone involved will benefit and positive patient outcomes can be expected.
AIM: To analyze the physician labor market in Croatia with respect to the internship and employment opportunities, Croatian needs for physicians and specialists, and trends in physician labor market in the European Union (EU) in the context of EU enlargement. METHODS: Data were collected from the Ministry of Health and Social Welfare, the Croatian Employment Service, and the Croatian Institute for Public Health. We compared the number of physicians waiting for internship before and 14 months after the implementation of the State Program for Intern Employment Stimulation. Also, the number of employed specialists in internal medicine, general surgery, gynecology and obstetrics, and pediatrics was compared with estimated number of specialists that will have been needed by the end of 2007. Average age of hospital physicians in the four specialties was determined and the number of Croatian physicians compared with the number of physicians in EU countries. RESULTS: The number of unemployed physicians waiting for internship decreased from 335 in 2003 to 82 in 2004, while a total number of unemployed physicians decreased from 436 to 379 (chi2=338, P<0.001). In October 2004, 79.3% of unemployed physicians waited for internship <6 months; of them, 89.2% waited for internship <3 months. In February 2005, 365 unemployed physicians were registered at the Croatian Employment Service and that number has been decreasing in the last couple of years. The number of employed specialists was lower than the estimated number of specialists needed in the analyzed specialists, as defined by the prescribed standards. A shortage of 328 internists, 319 surgeons, 209 gynecologists, and 69 pediatricians in Croatian hospitals is expected in 2007. CONCLUSION: The lack of employment incentive seems to be the main reason for the large number of unemployed physicians waiting for internship before the implementation of the Employment Stimulation Program. According to the number of physicians per 100,000 population, Croatia is below the EU average. Croatian labor market will not be able to meet the needs of the health system for physicians by the end of 2007.
OBJECTIVE: To compare specialist and primary care physician participation in California's Medicaid fee-for-service and managed care programs. DESIGN: Cross-sectional survey. PARTICIPANTS: A probability sample stratified by county and by race of 962 specialist physicians and 713 primary care physicians practicing in the 13 largest counties in California in 1998. MEASUREMENTS AND ANALYSIS: We used physician self-report from mailed questionnaires to compare acceptance of new Medicaid and new Medicaid managed care patients by specialists versus primary care physicians and by physician demographics, practice setting, attitudes toward Medicaid patients, and attitudes toward Medicaid managed care. We analyzed results using logistic regression with data weighted to represent the total population of primary care and specialist physicians in the 13 counties. MAIN RESULTS: Specialists were as likely as primary care physicians to have any Medicaid patients in their practices (56% vs 56%; P=.9). Among physicians accepting any new patients, specialists were more likely than primary care physicians to be taking new Medicaid patients but were significantly more likely to limit their acceptance to only Medicaid fee-for-service patients. Thus, specialists were much less likely than primary care physicians to accept new Medicaid managed care patients. After controlling for physician demographics, practice settings, and attitudes toward Medicaid patients and Medicaid managed care, specialists remained much less likely to accept new Medicaid managed care patients. CONCLUSIONS: Expansion of Medicaid managed care may decrease access to specialists as specialists were less likely to accept new Medicaid managed care patients compared to Medicaid fee-for-service patients. Any decrease in access may be mitigated if states are able to contract with group model HMOs and to recruit minority physicians.
STUDY DESIGN: A randomized controlled trial, prestest-posttest design, with a 3-, 6-, and 12-month follow-up. OBJECTIVES: To investigate the efficacy of a therapeutic exercise approach in a population with chronic low back pain (LBP). BACKGROUND: Therapeutic approaches developed from the Pilates method are becoming increasingly popular; however, there have been no reports on their efficacy. METHODS AND MEASURES: Thirty-nine physically active subjects between 20 and 55 years old with chronic LBP were randomly assigned to 1 of 2 groups. The specific-exercise-training group participated in a 4-week program consisting of training on specialized (Pilates) exercise equipment, while the control group received the usual care, defined as consultation with a physician and other specialists and healthcare professionals, as necessary. Treatment sessions were designed to train the activation of specific muscles thought to stabilize the lumbar-pelvic region. Functional disability outcomes were measured with The Roland Morris Disability Questionnaire (RMQ/RMDQ-HK) and average pain intensity using a 101-point numerical rating scale. RESULTS: There was a significantly lower level of functional disability (P = .023) and average pain intensity (P = .002) in the specific-exercise-training group than in the control group following the treatment intervention period. The posttest adjusted mean in functional disability level in the specific-exercise-training group was 2.0 (95% CI, 1.3 to 2.7) RMQ/RMDQ-HK points compared to a posttest adjusted mean in the control group of 3.2 (95% CI, 2.5 to 4.0) RMQ/RMDQ-HK points. The posttest adjusted mean in pain intensity in the specific-exercise-training group was 18.3 (95% CI, 11.8 to 24.8), as compared to 33.9 (95% CI, 26.9 to 41.0) in the control group. Improved disability scores in the specific-exercise-training group were maintained for up to 12 months following treatment intervention. CONCLUSIONS: The individuals in the specific-exercise-training group reported a significant decrease in LBP and disability, which was maintained over a 12-month follow-up period. Treatment with a modified Pilates-based approach was more efficacious than usual care in a population with chronic, unresolved LBP.
Previous studies of long-term outcome for personality disorder (PD) were either retrospective in design or did not include a control condition. In this paper we report results for three PD cohorts (N = 111) treated in two different specialist psychosocial programs (step-down and long-term inpatient) and in general psychiatric treatment as usual (TAU), which were prospectively followed up for 72-months after intake. The three PD samples were compared on symptom severity, social adjustment, global functioning and other clinical indicators (self-mutilation, parasuicide and readmission rates) at intake, 6, 12, 24, and 72 months. Results indicated that a specialist step-down model showed significantly greater change than a purely inpatient model and TAU in most key dimensions of functioning, a difference maintained at 72-months follow-up. Improvement in the samples was not associated with amount of intercurrent treatment received in the year prior to the follow-up assessment. This study confirms that a step-down program retains significant improvement associated with a specialist psychosocial approach for PD. However, this conclusion should be qualified by design limitations. The samples were not randomly allocated to the three conditions and the naturalistic geographical allocation used in the study created a potential for a number of confounds. Whilst we used extensive statistical controls, the possibility that the differences found between the groups may be due to population differences cannot be discounted.
OBJECTIVES: Accessing at-risk and underserved populations for intervention remains a major obstacle for public health programs. Emergency departments (EDs) care for patients not otherwise interacting with the health care system, and represent a venue for such programs. A variety of perceived and actual barriers inhibit widespread implementation of ED-based public health programs. Collaboration between local health departments and EDs may overcome such barriers. The goal of this study was to assess the effectiveness of a health department-funded, ED-based public health program in comparison with other similar community-based programs through analysis of data reported by health department-funded HIV counseling and testing centers in one Ohio county. METHOD: Data for HIV counseling and testing at publicly funded sites in southwestern Ohio from January 1999 through December 2002 were obtained from the Ohio Department of Health. Demographic and risk-factor profiles were compared between the counseling and testing program located in the ED of a large, urban teaching hospital and the other publicly funded centers in the same county. RESULTS: A total of 26,382 patients were counseled and tested; 5,232 were ED patients, and 21,150 were from community sites. HIV positivity was 0.86% (95% confidence interval [CI] 0.64%, 1.15%) in the ED and 0.65% (95% CI 0.55%, 0.77%) elsewhere. The ED program accounted for 19.8% of all tests and 24.7% of all positive results. The ED notified 77.3% of individuals testing positive and 84.4% of individuals testing negative. At community program centers, 88.3% of patients testing positive and 63.8% of patients testing negative were notified of results. All ED patients notified of positive status were successfully referred to infectious disease specialists. CONCLUSIONS: Public health programs can operate effectively in the ED. EDs should have a rapidly expanding role in the national public health system.
Economic constraints developing as a result of rising health care costs in the United States pose significant challenges for and threats to the survival of academic plastic surgery. Declining clinical revenues, competition for patients and resources from other health care providers, and reductions in support of its education and research efforts necessitate a paradigm shift if it is to survive. Questionnaires were used to collect data from 92 of the 100 postgraduate training program directors of plastic surgery in the United States. The most common source of clinical income on a national basis was indemnity insurance. Sources of clinical income varied by region. The majority of programs, 80 percent, report that at least 75 percent of the income support for faculty came from practice income. Financial support for ancillary and research personnel, in large part, came from this same source. Resident salaries and benefits came largely from other resources. Generally as population density within the metropolitan area in which a program was located increased, so too did the number of competing plastic surgeons, including graduates of the program and nonacademic cosmetic and hand surgeons. However, levels of competition for cosmetic surgery in smaller metropolitan areas of some regions seem to be similar to those reported by programs in larger communities. Plastic surgery programs in very competitive communities received significantly greater amounts of their income from indemnity insurance and self-paying patients than did programs in less competitive metropolitan areas. Internal competition from other surgical and nonsurgical specialists within the same institution is likewise keen. Virtually all respondents, 93 percent, report that their institutions provided patient care in a least one designated center of excellence in the following disciplines: hand, microsurgery, craniofacial, cleft lip and palate, burn, and cosmetic surgery. This study suggests that centers of excellence are more likely to be present in metropolitan areas with fewer competing surgeons than in areas with large numbers of competing surgeons. The data did not demonstrate that the presence of a center of excellence substantially affected the sources or levels of clinical income. To survive as an academic entity, program directors must correctly perceive and fulfill the needs and wants of its stakeholders, particularly with regard to quality of life issues.
OBJECTIVE: To ascertain babies born with spina bifida that was not detected by prenatal ultrasound examination performed after 16 weeks' gestational age at Western Australian referral centres, 1990-1991. DESIGN: A retrospective study of the antenatal ultrasound details of those infants born with spina bifida in Western Australia during the 24-month period, 1990 and 1991. Data were collected by interviewing parents, clinically assessing affected individuals and reviewing genetic, clinical and investigative records, and from the Birth Defects Registry of Western Australia. SETTING: Western Australia, which has a relatively high spina bifida birth prevalence of 1 in 1000, has centralised neonatal medical, surgical and genetic services, and a Birth Defects Registry. This enabled us to ascertain all Western Australian neonates with spina bifida for the purposes of this study. There is no universal maternal serum alpha-fetoprotein (MSAFP) screening program and the performance of ultrasonography at referral level is of variable quality. PARTICIPANTS: Newborns with spina bifida and their parents. MAIN OUTCOME MEASURES: Ultrasound screening for spina bifida was deemed to have failed when referral to a specialist imaging centre for the specific purpose of detecting anatomical abnormality after 16 weeks' gestational age gave a falsely negative result. RESULTS: Of the 47 infants born with spina bifida in 1990 and 1991, ultrasound screening at more than 16 weeks' gestational age was documented and was falsely negative in 14. Six of the 14 had a relevant family or medical history for the condition. Five of the lesions were covered and eight of the patients still survive. CONCLUSION: Ad-hoc fetal ultrasound examination via existing referral centres had obvious limitations in detecting spina bifida in a population at low risk. MSAFP screening has a well documented role in detecting neural tube defects, as eight to 10 of the 14 lesions missed by the referral ultrasonography would have been ascertained in a program of this nature. The study indicated that adequate pre-screening clinical histories were not sought, thus limiting the antenatal testing options offered to at-risk couples. This study emphasised the importance of a statewide review of the specificity and sensitivity of the anatomical fetal ultrasound examination, in view of the expansion of this procedure and its variable quality depending on operator experience and equipment quality.
Will primary care practices set up by physicians trained in combined internal medicine-pediatrics residencies be successful? To address this question, the recruitment of patients to the medicine-pediatrics office established in May 1985 by a northeastern medical center and the patients' understanding of and satisfaction with the combined practice were studied via the billing system and a questionnaire mailed to 1,001 households of patients in November 1988. Although equally divided between children and adults, the patient population had two large bulges, infants less than 2 years old and young adults aged 18-39 years. Most of the 833 patients (from 406 households) who returned the questionnaires were well educated and professional. They indicated they were aware of the nature of the practice; had been looking for a specialist, not a "doctor for the family"; and were highly satisfied. Therefore, the medicine-pediatrics residency program studied appears to have been very successful in preparing primary care physicians. These physicians had a particular appeal to young upper-middle-class families.
Socio-economic status (SES) has been reported as a causative factor of increasing health inequalities in industrialized countries. The phenomenon has been particularly investigated for job related diseases, including cardiovascular disease and risk. The group of occupational medicine specialists in the world wide MONItoring program of CARdiovascular disease (WHO-MONICA Project) is now producing a number of hypotheses about the application of internationally defined criteria and tools for SES evaluation in the Italian area of the Project, Area Brianza. After a short review of some main conceptual and methodological problems, a proposal is presented of an SES index, derived from the pooled data of two population surveys carried out in this area. From a randomized sample of 3200 residents, 25-64 years old, stratified by sex and age decade, 1731 subjects, 594 females and 1137 males, employed at the time of the screening were extracted. Four variables were considered: age, education, occupational level and job-strain (according to the Karasek-Theorell model) by which each subject was classified in three levels--high, medium, low--of education and occupation, whose combination was used to obtain as many levels of socio-economic status. This a method of building an SES index is based on a sequence of approximations following two essential criteria: limitation of the variables to be surveyed, through standardized procedures; ability to identify the "low" SES category, presumably more at risk for disease.
BACKGROUND: Guidelines from the National Heart, Lung, and Blood Institute, Bethesda, Md, have encouraged more frequent use of inhaled steroids in asthma management. OBJECTIVES: To determine (1) whether prescription rates for inhaled steroids have increased compared with prescriptions for bronchodilators and (2) significant associations of demographic factors with bronchodilator-inhaled steroid prescription ratios and with rates of inhaled steroid prescriptions. DESIGN: Cross-sectional analysis of monthly bronchodilator and inhaled steroid prescription rates, numbers and types of asthma care providers, and demographic factors. SETTING: Philadelphia, Pa. MEASUREMENTS: Using univariate and multivariate analyses, bronchodilator and inhaled steroid prescription rates were determined for 45 ZIP codes and studied for associations with race and ethnicity, poverty, educational attainment, marital status, gender, total numbers of asthma drug prescriptions, and numbers and types of asthma care providers. RESULTS: Monthly bronchodilator-inhaled steroid prescription ratios increased from July 1991 to June 1993 (P < .001). Prescription rates for inhaled steroids and inhaled bronchodilators declined, but rates for oral bronchodilators (beta-agonists and theophylline) increased. By stepwise multiple regression, higher bronchodilator-inhaled steroid prescription ratios and lower inhaled steroid prescription rates were each significantly associated with ZIP codes in which greater proportions of residents lacked a high school diploma (P < .001); associations that approached statistical significance were found for higher bronchodilator-inhaled steroid ratios and fewer asthma care providers (P = .05) and for lower inhaled steroid prescription rates and lower proportions of asthma specialists (P = .04). CONCLUSIONS: In Philadelphia, a gap exists between optimal asthma drug prescribing and actual prescribing patterns that has widened from July 1991 to June 1993. Underuse of inhaled steroids is most closely associated with lower educational attainment, suggesting that interventions that include addressing the special asthma care needs of a low-literacy population will be required to achieve the goals of the National Asthma Education Program.
During the past few years, the effectiveness of neighborhood health centers (NHCs) has been questioned, and curtailment of funding has indicated a lack of confidence in this organizational model. This article, however, reports on an urban NHC which has achieved considerable success in delivering health care to its target population at a moderate cost. Fifty-two per cent of all community residents and three-quarters of the children and adolescents were active users of the center. The majority of the patients were from low-income families and had established long-term relationships with center providers. Average visits per patient varied with age, sex, diagnosis and insurance coverage. Center physicians, trained as specialists, functioned primarily as general practitioners delivering preventive services, treating minor injuries and self-limiting diseases, and palliating chronic illness. Preventive care was planned as a focal point of the center's program, but third-party reimbursement policies and the lower priority that many patients placed on nonillness care were two major obstacles to the achievement of this goal. The average cost of health care other than mental health services was approximately $20 per visit and $74 per patient per year. Mental health treatment was more expensive. The findings suggest that reconsideration of the NHC as a viable model for delivering health care to the poor might be worthwhile.
UNLABELLED: This self-directed learning module highlights consideration and treatment of individuals with long-term spinal cord injury (SCI). It is part of the chapter on SCI medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the challenges of chronic disease prevention, diagnosis, therapeutic options, and the resultant impact on the person with long-term SCI. With cardiovascular disease becoming a leading cause of mortality in this population, risk factor modification through weight, lipid, and glucose control becomes more important. Likewise, bowel dysfunction increases with duration and severity of SCI. Conservative and surgical management options are discussed. Musculoskeletal repetitive trauma injuries occur commonly in long-term SCI but can be prevented with appropriate lifestyle or equipment modifications. These and other conditions occurring in the person with long-term SCI are closely related to psychosocial function with resultant social isolation, depression, and substance abuse. Thus, identification and surveillance of these comorbidities are addressed, with an emphasis on prevention. OVERALL ARTICLE OBJECTIVE: To summarize the unique medical, psychosocial, and functional needs of the individual with long-term SCI.
BACKGROUND: The evolution of American health care into integrated systems of delivery and finance requires a specialized set of population-based skills for physicians. The field of preventive medicine represents one source of this expertise. Specific competencies for the emerging area of managerial medicine have not been well delineated. METHODS: Using concept documents from the Residency Review Committee for Preventive Medicine and the American Board of Preventive Medicine, a list of proposed competencies for managerial medicine was identified. Surveys were mailed to medical directors of all members of the American Association of Health Plans and to a random sample of diplomates of the American Board of Preventive Medicine. Respondents were asked to rate the importance of these competencies for a population-oriented clinician manager. RESULTS: Areas rated highly by medical directors included health services research (including outcome research), quality assurance and improvement, health risk assessment and reduction, programmatic skills, and clinical preventive skills. Responses from preventive medicine specialists were similar, but placed lower emphasis on these skills. CONCLUSION: Despite its limited response rate, this survey may be useful in the implementation of specialty training in managerial medicine. Residency training programs may choose to emphasize specific content area that reflect the priorities expressed by physicians actively involved in management.
This study examines the relationship between socioeconomic advantage and the likelihood of receiving specialty care in a nationally representative sample of older Americans participating in fee-for-service Medicare. In 1992, 62.9 percent of Americans aged 65 and older visited a specialist physician at least once. Being white, having more education, and having a higher income were each independently associated with a higher likelihood of visiting a specialist. Having insurance to supplement basic Medicare coverage was also independently associated with an increased likelihood of visiting a specialist; disadvantaged elders are less likely to have such supplemental insurance. Therefore, based both upon socioeconomic disadvantage and a lack of insurance to supplement the basic Medicare benefit, black, less educated and low-income elders are less likely to receive specialty services under fee-for-service Medicare. As the program evolves, it will be important to continue to monitor access to specialty care in vulnerable, socioeconomically disadvantaged populations.
A fully capitated, integrated healthcare delivery system endeavored to improve the care of its sickest members. A computer algorithm severity index that encompassed a 1-year history of hospitalization and adjusted for inclusion of a variety of chronic conditions was calculated on the basis of clinical and administrative claims databases for the entire membership of the healthcare system. Monthly updated lists were produced to find patients with acute and chronic illnesses. These patients accounted for one-fourth of hospital admissions and almost half of inpatient days, but they numbered less than 1% of system membership. Each listed person, regardless of age or diagnosis, had a custom care plan formulated by nurses in consultation with the primary care physician and involved specialists. Plan development featured in-home assessments in most instances and incorporated a variety of ancillary services, telephone and home-care follow-up, and strategies to increase continuity and access to care. Patient-reported functional status was obtained at establishment of the care plan and periodically thereafter in expectation of raising the cross-sectional mean values of the population. Three months after initiation of the program, the expected winter hospitalization peak did not occur, and utilization tended to be lower in subsequent months. Inpatient admissions among members with acute and chronic illnesses decreased 20%, and inpatient days decreased 28% from baseline levels. Among the subset of seniors in the population, inpatient days decreased 37%. Net financial impact was a medical expenditure decrease of more than 5% from 1995 levels. On a population basis, functional status was raised, and the acuity of patients' conditions and need for inpatient hospital care were reduced.