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PubMed1976

Screening and supportive techniques for home dialysis in the treatment of renal failure.

Patients with end-stage renal disease are being kept alive by dialysis treatment which may be provided either in an institution or in the patient's home. However, medical advancements have outstripped the ability of the treatment team to insure the quality of life for these long-term patients. Although the predominant pattern of care continues to be the hospital- or institution-based unit, an attempt is being made by both patients and physicians to make home dialysis a more viable alternative. There are two major barriers to the large-scale effectiveness of treatment by home dialysis: 1) lack of criteria for the selection of candidates, and 2) lack of a continuing supportive service system. Home care requires a total understanding of the psychosocial functioning of the patient and the family.

Costs and Cost Analysis↗
PubMed1977

Chorioretinitis in the adolescent: two case presentations with discussion.

Two cases of chorioretinitis in adolescence demonstrate the characteristic course of events. It is typically caused by Toxoplasma gondii and is usually acquired congenitally. Toxocara infection must be considered in younger children. Other etiologic agents are rarely implicated in children and youth. Diagnosis of toxoplasmic chorioretinitis is based on a characteristic history of visual disturbance and specific funduscopic appearance, along with confirmatory serological studies. Management is complex, utilizing pyrimethamine (Daraprim), sulfadiazine, and prednisone in combination for several weeks or months. The combined long-term care by the physician generalist and ophthalmologist is essential. Recognition of adolescent developmental issues is important to insure optimal compliance. The prognosis is guarded, with 5% to 30% recurrence rates noted after treatment. Severe visual impairment may be seen.

Adolescent↗
PubMed1977

Nutrient intake and stimulant drugs in hyperactive children.

Recent studies have demonstrated suppressed growth of height and weight in children receiving stimulant drugs for hyperactivity. For approximately twelve months, growth data and food records were collected on two subjects receiving different types and dosages of stimulant drugs. The two cases demonstrated that dextroamphetamine levels of 10 mg. or more and methylphenidate levels of 30 mg. or more decreased caloric intake significantly. This decrease may be limiting for long-term growth. Both subjects had a variety of feeding problems due to poor appetite. Careful nutritional evaluation and planning are important to insure optimal energy and nutrient intake in these children receiving stimulant drugs.

Ascorbic Acid↗
PubMed1979

Delivering ambulatory health care: the successful experience of an urban neighborhood health center.

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.

Adolescent↗
PubMed1979

[Rehabilitation of brain-injured patients--demonstrated with the help of a successfully performed individual rehabilitation plan (author's transl)].

According to 5 Sect. 3 of the Act on the Standardisation of Rehabilitation Services (Rehabilitations-Angleichungsgesetz) an individual rehabilitation plan must be set up if several rehabilitation measures, e.g., medical, vocational and social measures are necessary, or, if different rehabilitation agencies are financially responsible for these procedures. This applies, as a rule, to the rehabilitation efforts for the severely brain-injured. The case history of a young brain-injured patient is used to demonstrate that an overal improvement can be achieved if a close co-operation between the hospital, rehabilitation centre, attending doctor, rehabilitation agencies and employers is ensured. The different measures must be adapted to the individual degree of work tolerance of the patient. Out-patient measures should be carried out -- and this not only because of the lower costs involved. The so-called "Anschlussheilverfahren" which means a treatment programme following the acute phase, initiated by the responsible agencies for the pension insurance scheme, does not seen to be the appropriate routine treatment to be carried out in the rehabilitation of the brain-injured, as they require more comprehensive and long-term therapy.

Adolescent↗
PubMed2026

Transcranial Magnetic Stimulation for Patients with Exposure Therapy Resistant Obsessive-Compulsive Disorder (TETRO): Study Protocol for a Multicenter Randomized Controlled Trial.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a disabling mental disorder, characterized by obsessions, compulsions, and substantial morbidity. Approximately 50% of adults with OCD fail to achieve satisfactory outcomes from first-line treatments, such as exposure therapy with response prevention (ERP), with or without medication. This leads to chronic social, educational, and occupational impairment. While invasive procedures such as deep brain stimulation are available for severe, treatment-refractory cases, a need remains for less invasive alternatives. Repetitive transcranial magnetic stimulation (rTMS), a noninvasive intervention, shows promise in reducing OCD symptoms. Unlike in depression, rTMS is not yet reimbursed for OCD in the Dutch healthcare system. OBJECTIVE: This study examines the efficacy and cost-effectiveness of low-frequency (1Hz) rTMS targeting the presupplementary motor area (pre-SMA) compared to sham rTMS as an adjuvant treatment to ERP in adults with OCD with inadequate response to first-line treatment. METHODS: A total of 250 adults with OCD will be enrolled in this multicenter randomized controlled trial. Participants will be randomly assigned to ERP combined with either active or sham 1Hz rTMS over the pre-SMA. Treatment is administered 4 times weekly for at least 5 weeks (20 rTMS-ERP sessions), with optional extension of 1 to 2 weeks, up to 28 rTMS-ERP sessions. Clinical assessments occur at baseline, weekly during treatment, posttreatment, and at 3, 6, and 12 months follow-up. Participants undergo pre- and posttreatment (functional) (MRI) scans, including a symptom provocation task. Blood sampling takes place pre- and posttreatment and at 3-month follow-up. The primary outcome is OCD severity at posttreatment, as measured by the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Secondary outcomes include functional improvement, quality of life, and societal costs. Pretreatment symptom profiles, genotype, and brain network topology will be analyzed as predictors of response and relapse risk. Pre-to-post treatment change in blood-based and magnetic resonance (MR)-based neuroplasticity markers will help explore differential mechanisms between ERP alone and combined rTMS-ERP. We expect that the verum rTMS protocol will be cost-effective compared to sham-rTMS. RESULTS: Recruitment started in April 2022, and as of February 2026, 201 participants have been enrolled. Posttreatment assessments are projected to be completed in December 2026, with final one-year follow-up evaluations anticipated by the end of 2027. CONCLUSIONS: To our knowledge, this study is the first adequately powered randomized controlled trial examining efficacy, cost-effectiveness, and mechanism of action of rTMS for OCD as adjuvant therapy to ERP. In case of efficacy and/or cost-effectiveness, it will pave the way for rTMS as insured health care for adults with OCD in the Netherlands, and possibly other European countries. Furthermore, this trial will provide insight into the mechanisms of treatment response to intensive ERP, with and without adjunctive rTMS, as well as potential side effects, individual variability, and long-term outcomes in adults with OCD.

Humans↗
PubMed1979

Implementing a multiphased hospice program.

By implementing a hospice program in three phases, each of which can be integrated with existing services in general acute care and long-term care facilities, a health care institution can provide the community with an important new service. And the parent organization incurs only the cost or providing additional inservice and medical education.

Day Care, Medical↗
PubMed1977

Cost, utilization, and utilization review of mental health services in a prepaid group practice plan.

The author describes the utilization review process, utilization patterns, and service cost of the Mental Health Service of the Health Insurance Plan of Greater New York (HIP). He finds that a mental health care delivery system within a health maintenance organization offers the advantages of sophisticated utilization review procedures, reduced cost per mental health incident, and a low utilization rate and low cost for psychiatric hospitalization. However, the HMO's return-to-function treatment goals may be too limited for the minority of patients who would benefit only from long-term intensive treatment. He recommends that cost accounting be based on cost per illness rather than cost per service.

Accounting↗
PubMed1992

[The objectives, failures and new ways in hospital aftercare and rehabilitation].

One of the main aims of oncological aftercare is to improve the transition from acute into chronic medicine, i.e. from curative into rehabilitative treatment. The somatic, psychic, social, professional, and family problems due to the tumour and its therapy have to be eliminated, improved or prevented. Up to now, oncological rehabilitation often was considered an isolated measure. The lack of cooperation between curative and rehabilitative medicine often resulted in the fact that patients in need of aftercare were not sent to appropriate rehabilitation clinics. There was no feed-back between pre- and after-treating doctors. The recommendations of the commission for further development of rehabilitation in the social insurance (VDR), elaborated together with the study-group for rehabilitation and aftercare and the study-group for the protection of the quality standard in oncology, aim at improving the above mentioned target. Active and forward-looking measures should improve the significance of clinical aftercare. The documentation of rehabilitation needs will allow more differentiated rehabilitation measures and long-term evaluation of their success. For a more effective integration of rehabilitative aspects into primary treatment, there is the demand for a closer cooperation between primary care and aftercare.

Aftercare↗
PubMed1992

[Hospital crisis and the hospital of the XXI century].

The present hospital situation and a projection for the XXIth century, the national and international information, is analyzed. Outstanding characteristics include better health indicators and an explosive growth of costs due to technological advance and health insurance. Inadequate use of resources is noted. The state expense in public health was greatly decreased during the Chilean military government who privileged private investment. At present, the public sector counts 184 hospitals, 373 outpatient clinics and 1053 rural health posts and takes care of the health needs of 80% of the population. There has been no increase in expenses in the public sector compared to a 150% increase in the number of beds in the private sector. Decentralization, a redefinition of the health care model, an investment program and better administration are needed to improve the situation long-term. The health system and levels of health care as well as a model for hospitals in the coming century are described.

Chile↗
PubMed1975

Practical care for the family of a child with cancer.

Support of the child with cancer and his family has two main components: emotional and practical. Since there are already many excellent reviews on emotional care, this discussion covers some of the practical ways to provide help. All the following suggestions are time consuming and some are costly: 1) Physical facilities should include an oncology ward and a special clinic able to provide day care. Adequate arrangements should be availble for parents to stay overnight. 2) Financial resources should be discussed early during the course of the disease to insure adequate coverage and prevent accumulation of debts. Loan and social service funds are a valuable addition to the service. 3) Parent Groups can be organized with differing objectives such as group therapy or community action.

Child↗
PubMedDate not supplied

[Medico-economic assessment of neuroleptics in schizophrenia. Amisulpride versus haloperidol].

The aim of this study is to assess the economic impact of neuroleptic strategies in the long-term treatment of schizophrenic patients. In this respect a new neuroleptic strategy (amisulpride) was compared to a reference drug (haloperidol) using a cost minimization method. Clinical, demographic and economic (direct medical costs) data were obtained retrospectively from patients' charts. Patients (n = 160) were randomly selected according to diagnosis (schizophrenia, DSM III-R), treatment (outpatient, amisulpride or haloperidol) and follow up period (at least 6 months). The health insurance point of view was selected for the economic analysis. We found a significant reduction of the annual number of days of relapse when patients were treated with amisulpride compared to haloperidol. This reduction was associated with a significant reduction of direct costs mainly related to shorter length of hospitalization. This result was only partly explained by demographic and clinical variables such as the severity of the disease. The differences remained significant when populations were matched. This finding illustrates the validity of the concept of efficiency in psychiatry.

Ambulatory Care↗
PubMed1975

The prevalence of long-term illness among the elderly in a general practice.

A retrospective study was performed to assess the prevalence of long-term illness in all patients aged 65 years and over in the practice of one family physician. Of 191 patients (10,6% of the practice population), 87% suffered from at least one illness and the mean prevalence rates were 2 129 diagnoses per 1 000 males and 1 955 for females. Fifty-eight per cent of the women and 14% of the men were widowed. The prevalence rates of 16 diagnostic categories are presented and compared with their prevalence among the general population. The findings are discussed with reference to the need for functional assessment and for prevention or relief of disability, so as to enable the individual to remain reasonably independent. The implications are discussed in relation to the need for the family physician to undertake increased responsibility for the comprehensive medical care of the elderly.

Age Factors↗
PubMedDate not supplied

Home health services in New Hampshire.

While home health services have traditionally been an underused component of the health care system, current trends suggest the desirability of expanding these services. These trends include an increase in the number of elderly who need the benefits of home care, the recognition that long-term chronic illnesses require appropriate management at home, and concern that patients have access to care at the level most appropriate to their illnesses. In New Hampshire, 41 certified home health agencies offer services. Little systematic research has been conducted on the kinds of services they provide and the patients seen by their staffs. Patient encounter data were collected from a sample of eight agencies for a 4-week period. Staff of the agencies used the patient contact record developed by the National Functional Task Analysis Cooperative Study to collect data. The data reflected differences among the agencies in the size of the populations they serve, organizational characteristics, reasons for patients' visits, expected sources of the revenue that supported them, and the diagnosis of the patients they cared for. The agencies served areas with populations ranging from 1,000 to 40,000. The staffs ranged from 1 to 14 full-time persons. Two were public agencies; the others had voluntary sponsorship. When data on reasons for visits were averaged for the eight agencies, it was shown that 72% of the visits were made for disease control activities such as care for a chronic or acute condition or for treatment or a laboratory test. Disease prevention activities such as a checkup for adults, children, prenatal or postnatal care, or health education accounted for only 24% of the visits. This result may indicate that, in areas short of physician manpower, the community health nurse is taking on increasing responsibility for medical care as well as health and education. Reimbursement for the visits came from Medicare, 25%; Medicaid-welfare, 14%; the patients, 18%; and health insurance, 3%. For 35% of the visits there was no charge; they were underwritten by community resources.

Adolescent↗
PubMed1975

Outpatient management of anticoagulation.

The Anticoagulation Service insures uniformity of approach to the regulation of anticoagulation for patients of hospital-based primary physicians. There has been no anticoagulant-related mortality in 254 patient treatment-years, and the major complication rate is 4% of treatment courses. There is a relatively low complication rate because of the systematic approach to anticoagulation therapy, recognition of the importance of patient education, communication with the primary physician, and flexibility of drug dosage and patient visit regimens. Achieving the therapeutic range of the prothrombin time with minimum complications is the goal of this Service. The hallmark of adequate control is predictable response of the prothrombin time to adjustments in drug dosage. Statistical analysis of six years' experience has provided support for the thesis that control of anticoagulation and incidence of complications are not significantly altered by patient age, sex, or the presence of concurrent nonthromboembolic medical illness.

Administration, Oral↗