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PubMed1990

Practice guidelines and professional autonomy in a universal health insurance system: the case of tissue plasminogen activator in Ontario.

Ontario's universal health insurance system has placed few constraints on the clinical and economic autonomy of medical doctors. Although fees are standardized, most physicians remain in private fee-for-service practice and thereby retain control of the mix and volume of services. Utilization review is minimal. While organized medicine has argued that health care is 'under-funded', the government is pressing for better use of extant resources through firmer management of the medical services sector. The Ontario Medical Association (OMA), the major bargaining agent for doctors in the province, has accordingly sought to protect professional autonomy by developing voluntary self-regulatory approaches that obviate the need for external controls over physician practice patterns. Part of this strategy is promulgation of practice guidelines. Tissue plasminogen activator (t-PA), a clot-lysing drug for myocardial infarction, was released in late 1987, and, at C$2950 per treatment, constituted an unforeseen add-on cost for hospitals. The OMA subsequently convened an expert panel to develop guidelines for thrombolysis in myocardial infarction. Among the unanticipated results was the conclusion that insufficient evidence had accumulated to recommend routine use of t-PA instead of streptokinase, an older drug costing C$290. The OMA panel's guidelines were approved by the OMA executive, and led the government to reject special add-on funding for hospitals purchasing t-PA. The OMA's position and government decision provoked negative reactions from the OMA's own cardiology section. Indicative of clinicians' feelings, a follow-up survey of cardiologists and internists showed that only 28% of respondents were indifferent between t-PA and streptokinase, while 64% preferred t-PA. On the other hand, 74% supported clinical policy development by the OMA, while 94% opposed direct government involvement in guideline-setting. The case of the OMA thrombolysis guidelines illustrates a strategic conundrum facing Canadian organized medicine. Professional activism in guideline-setting may in theory protect the individual practitioner's autonomy by offering a voluntary alternative to utilization management by government, and is likely to strengthen the collective influence of organized medicine. However, among the risks are alienation of practitioners who see professional guidelines and government control as two sides of the same regulatory coin, and the transmogrification of voluntary guidelines into parameters for cost control and utilization management by government or hospitals. Future initiatives will depend on how these benefits and risks are weighed.

Cost Control↗
PubMed1984

Combined services of a community hospital and clinic to provide antineoplastic drugs for outpatients.

An outpatient antineoplastic drug service that uses the services of a community hospital and clinic is described. The hospital pharmacy department assumed responsibility for preparing doses of antineoplastic drugs for use in a local medical clinic; previously, clinic nursing staff prepared the doses on a countertop. To provide this service, the hospital purchased a vertical laminar-flow safety cabinet, developed policies and procedures, and devised standard dilution protocols. The pharmacy maintains patient profiles for all outpatients. Each physician order is telephoned to the pharmacy from the clinic followed by delivery of the written order to the pharmacy via a courier service. After review of the written order by a pharmacist, the courier delivers the medication to the clinic. Since beginning the service December 1982, the pharmacy has prepared an average of three doses of antineoplastic drugs per day; about one hour of pharmacist time per day is devoted exclusively to this service. Revenue from the service has covered start-up costs and has generated profit. By using the combined resources of health professionals in the community, quality care is provided to outpatients receiving cancer chemotherapy.

Antineoplastic Agents↗
PubMed1994

Handwashing machines, handwashing compliance, and potential for cross-contamination.

Although handwashing is considered an important factor in the prevention of nosocomial infections, the optimal technique has not been determined and compliance is often difficult to obtain. Handwashing compliance is particularly important in intensive care areas of the hospital. In an effort to improve HW compliance, the surgical intensive care unit in our hospital purchased three handwashing machines. Four months after installation of the handwashing machines, an outbreak of methicillin-resistant Staphylococcus aureus occurred in the intensive care unit. As part of evaluating the outbreak, we cultured the handwashing machines, including the portholes and the paper towel dispenser. Cultures were positive for methicillin-resistant Staphylococcus epidermidis, Achromobacter species, and Streptococcus viridans. The design of the handwashing machines made contamination of sleeves and already-washed hands possible. An observational study revealed that handwashing compliance was poor but improved from 22% to 38% when the handwashing machines were in use. Nurses preferred handwashing at the sink and physicians preferred the handwashing machine. Handwashing machines may increase handwashing compliance because of their novelty, but they may also result in novel problems.

Cooperative Behavior↗
PubMedDate not supplied

The direct costs of universal precautions in a teaching hospital.

An analysis of the increase in expenditures for barrier isolation materials before and after the institution of universal precautions at our 900-bed university hospital was used to generate a national estimate of the cost of implementation of the new Centers for Disease Control guidelines. Following the institution of universal precautions, use of rubber gloves at our hospital increased from 1.64 million pairs of 2.81 million pairs annually. A 5-year review of hospital purchasing and supply records in both inpatient and outpatient areas indicated that the total annual costs for isolation materials increased by $350,900. This represented an increase from $13.70 to $22.89 per admission (60%) after adjustment for inflation. The cost of isolation materials increased from $98 to $215 per 1000 outpatient visits, an adjusted increase of 92%. Two thirds of the increase (64%) was due to rubber gloves and an additional 25% was due to disposable isolation gowns. Universal precautions are estimated to have cost at least $336 million in the United States in fiscal year 1989 after adjustment for inflation. If expenditures for isolation materials at our medical center are representative, previous estimates may have significantly underestimated costs nationwide.

Centers for Disease Control and Prevention, U.S.↗
PubMed1999

Improved survival following massive transfusion in patients who have undergone trauma.

HYPOTHESIS: Survival following massive transfusion in patients who have undergone trauma has improved during the past 10 years. DESIGN: Retrospective cohort study. SETTING: Academic level I trauma center in an urban community. PATIENTS: All patients who underwent trauma and who received greater than 50 U of packed red blood cells or whole blood in the 48 hours following admission to the emergency department. INTERVENTIONS: Data were obtained from blood bank records, the trauma registry, patient medical records, and hospital purchasing records. Patients were divided into 2 groups for comparison (early [1988-1992] and late [1993-1997] periods). MAIN OUTCOME MEASURES: Survival and changes in trauma care provision. RESULTS: Survival following massive transfusion in patients who have undergone trauma has significantly increased during the past 10 years (16% vs 45%, early vs late period, P = .03). Factors associated with poor outcome included male sex, major vascular injury, high Injury Severity Score, severe acidosis, prolonged hypotension, refractory hypothermia, and decreased use of platelet transfusion (all P<.05). In the later period, there was more aggressive correction of coagulopathy, more efficient use of warming measures, decreased operative times for the initial operation, and increased use of component therapy (all P<.05). CONCLUSIONS: Survival following massive transfusion has significantly (P = .03) increased during the past 10 years. Factors that may have contributed to this include more effective and efficient rewarming procedures, improved application of damage control techniques, more aggressive correction of coagulopathy, and improved blood banking procedures.

Adult↗
PubMed1995

The cost of childhood asthma to Australian families.

There have been no estimates of the actual cost of asthma care to Australian families. Previous estimates have been of the total cost to the community and have relied upon data collected by government departments and agencies. It was the aim of this investigation to estimate the cost of childhood asthma from the parents perspective in Australian families. A total of 238 asthmatic children aged 8-12 years were identified through prevalence studies of asthma in Sydney and Belmont, N.S.W. Children were selected if they had wheezed in the previous 12 months, had used asthma medicines or had airway hyperresponsiveness when tested. The study sample had a wide range of asthma severity. Data were collected retrospectively and prospectively. Parents completed a questionnaire which asked about health insurance and special asthma equipment costs in the previous 12 months. Every 2 weeks for a total of 3 months between February and June parents completed further questionnaires which assessed costs incurred because of their child's asthma, together with time spent obtaining treatment. Items included doctor consultations and tests, alternative practitioner consultations and tests, medications and alternative therapies purchased, hospital and ambulance use, and the cost of childcare as a consequence of asthma. We collected two or more months of prospective data from a total of 193 children. The mean annual cost of asthma to the family was A$212.48 per asthmatic child and 13.4 hr were spent obtaining treatment. For the group of children who had not visited a doctor in the previous year, the mean annual cost was A$85.60 and 13.1 hr were spent obtaining treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Asthma↗
PubMed2005

Road mobility and the risk of road traffic accident as a driver. The impact of medical conditions and life events.

STUDY OBJECTIVE: We conducted a longitudinal investigation of the impact of self-reported life events and medical conditions on changes in road mobility on the wheel between 2000 and 2002 in order to assess whether these changes would affect the risk of road traffic accident (RTA). METHODS: Data are from a cohort of workers and retirees from the French national gas and electricity companies (the Gazel cohort). In the present study, 10,483 participants were included (7843 men aged 51-61 years and 2640 women aged 46-61 years, in 2000). The link between mobility and the risk of RTA was approximated using data on RTA number during lifetime and reported mobility in 2000. We then compared changes in road mobility between 2000 and 2002 resulting from life events and medical conditions reported to have occurred in the year 2001 or changed when compared to year 2000. We also compared road mobilities in 2000 in order to assess any pre-existing differences before life events and medical conditions. This led to estimation of the effect of road mobility changes on the risk of RTA. RESULTS: Changes in road mobility associated with life events and medical conditions were only found among men. These changes in road mobility were minimal. Ensuing changes in the risk of RTA were estimated to be small (odds-ratios ranged from 0.94 to 1.01). The only life events found to be associated with increased road mobility was an important purchase. Hospitalization, serious RTA, and retiring were associated with reduced road mobility. Concerning medical conditions, men who reported cataract, angina pectoris, diabetes, anxiety and stress, sleep disorder, and depression decreased their road mobility. CONCLUSION: We found no or moderate changes in road mobility resulting from life events and medical conditions, suggesting that results from previous published studies that assessed the impact of life events or medical conditions on RTA were not jeopardized by improper adjustment for road mobility.

Accidents, Traffic↗
PubMed1995

A program proposal for new technology assessment.

New perioperative technology is developing constantly. To ensure the integration of quality, effectiveness, efficacy, and efficiency in patient care, an overall structure to new technology assessment should be implemented. This program for technology assessment, evaluation, and implementation was created to be a cohesive process using both human and monetary resources and to incorporate a cooperative plan used by all services within the mission of the hospital and under the guidance of administrative services.

Decision Making, Organizational↗
PubMed2004

Materials management and logistics in the emergency department.

The modern ED must create a clinical environment that has a predictable and sustainable production process equal to the needs of the patients. This means careful analysis of supply and equipment needs but also of costs and revenue challenges. Prediction models and contemporary supply chain management tools go a long way in assisting the manager to meet this need and in maintaining a clinically competent and financially stable ED.

Budgets↗
PubMed1998

The ventilator: selection of mechanical ventilators.

A comprehensive ventilator selection process can be a time-consuming and an overwhelming task. The needs assessment becomes the primary driving tool in the design of the selection process. From the needs assessment, the evaluation can be planned and organized according to the facility requirements, time constraints, and resources. The strategy can expand to an extensive project or have a succinct and condensed design. The needs assessment determines the criteria for the selection, whether it be cost, ventilator specifications, educational needs, manufacturer support needs, maintenance requirements, accessory items, or combinations of any item. Once the data have been collected, it must be analyzed and critiqued. How this examination is performed can be expansive or scaled down according to the facility's resources. Important items in the selection must be maintained and used more extensively in the decision, whereas less important items take a backseat in the operation. The final selection comes from the culmination of the entire process.

Equipment Design↗
PubMed1984

A potential infection hazard associated with the use of disposable saline vials.

Nosocomial respiratory tract infections have occasionally been associated with contaminated respiratory therapy devices and techniques. In the past two years, our hospital purchased disposable saline squeeze vials for use during suctioning of intubated patients. These vials have a cap which must be flipped or twisted-off by the user before the contents can be instilled into the patient's respiratory tract. We observed use of this item in our intensive care units (ICU) and studied the potential for contamination. ICU nurses use ungloved hand(s) to flip or twist-off squeeze vial cups resulting in skin contact with the vial opening. Cultures of nurses' hands and squeeze vial contents were obtained in the ICU where 24 nurses opened 92 vials in the manner previously described. Twenty-three percent of vial contents were contaminated and cultures revealed S. epidermidis, S. aureus, Streptococcus viridans and enterococcus. On six occasions, organisms recovered from vial contents were believed to be identical to organisms isolated from the hands of the nurse who opened the vial. When nurses used care in removing the saline vial cap, cultures of vial contents were sterile.

Bacterial Infections↗
PubMed2001

Changing concepts in long-term central venous access: catheter selection and cost savings.

BACKGROUND AND OBJECTIVES: Long-term central venous access is becoming an increasingly important component of health care today. Long-term central venous access is important therapeutically for a multitude of reasons, including the administration of chemotherapy, antibiotics, and total parenteral nutrition. Central venous access can be established in a variety of ways varying from catheters inserted at the bedside to surgically placed ports. Furthermore, in an effort to control costs, many traditionally inpatient therapies have moved to an outpatient setting. This raises many questions regarding catheter selection. Which catheter will result in the best outcome at the least cost? It has become apparent in our hospital that traditionally placed surgical catheters (ie, Hickmans and central venous ports) may no longer be the only options. The objective of this study was to explore the various modalities for establishing central venous access comparing indications, costs, and complications to guide the clinician in choosing the appropriate catheter with the best outcome at the least cost. METHODS: We evaluated our institution's central venous catheter use during a 3-year period from 1995 through 1997. Data was obtained retrospectively through chart review. In addition to demographic data, specific information regarding catheter type, placement technique, indications, complications, and catheter history were recorded. Cost data were obtained from several departments including surgery, radiology, nursing, anesthesia, pharmacy, and the hospital purchasing department. RESULTS: During a 30-month period, 684 attempted central venous catheter insertions were identified, including 126 surgically placed central venous catheters, 264 peripherally inserted central catheters by the nursing service, and 294 radiologically inserted peripheral ports. Overall complications were rare but tended to be more severe in the surgical group. Relative cost differences between the groups were significant. Charges for peripherally inserted central catheters were $401 per procedure, compared with $3870 for radiologically placed peripheral ports and $3532 to $4296 for surgically placed catheters. CONCLUSIONS: Traditional surgically placed central catheters are increasingly being replaced by peripherally inserted central venous access devices. Significant cost savings and fewer severe complications can be realized by preferential use of peripherally inserted central catheters when clinically indicated. Cost savings may not be as significant when comparing radiologically placed versus surgically placed catheters. However, significant cost savings and fewer severe complications are associated with peripheral central venous access versus the surgical or radiologic approach.

Catheterization↗