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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↗

PubMed1992

Getting by at home. Community-based long-term care of Latino elders.

Although evidence suggests that the morbidity and mortality of Latino elders (of any Hispanic ancestry) are similar to those of non-Latino whites, Latinos have higher rates of disability. Little is known about influences on the use of in-home health services designed to assist disabled Latino elders. We examine the effects of various cultural and structural factors on the use of visiting nurse, home health aide, and homemaker services. Data are from the Commonwealth Fund Commission's 1988 national survey of 2,299 Latinos aged 65 and older. Mexican-American elders are less likely than the average Latino to use in-home health services despite similar levels of need. Structural factors including insurance status are important reasons, but acculturation is not pertinent. Physicians should not assume that Latino families are taking care of their disabled elders simply because of a cultural preference. They should provide information and advice on the use of in-home health services when an older Latino patient is physically disabled.

Activities of Daily Living↗

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

Equality, autonomy, and efficiency: what health care system should we have?

The U.S. has a wide range of options in choosing a health care system. Rational choice of a system depends on analysis and prioritization of the basis moral goals of equitable access to all citizens, the just sharing of financial costs between well and ill, respect for the values and choices of subscribers and patients, and efficiency in the delivery of costworthy care. These moral goals themselves, however, tell us little about what health care system the United States should have. Equitable access does not demand a level and scope of care for the poor equal to that rationally chosen by the middle class, and there are ways within mixed systems, though not easy ways, to achieve a fair distribution of costs between well and ill. Despite pluralistic systems' apparent advantage in allowing subscribers to choose their own forms of rationing, problems in translating serious long-term subscriber choices into actual medical practice may be greater in pluralistic than in unitary systems. Final choice of a system hinges primarily on peculiar historical facts about U.S. political culture, not on moral principle.

Community Participation↗

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↗

PubMedDate not supplied

Status I heart transplant patients: conventional versus ventricular assist device support.

Since 1985, 59 United Network for Organ Sharing status I patients have been considered for heart transplantation. Thirty-four patients were supported with drugs and/or intraaortic balloon pump (IABP) (group I). Twenty-five patients were supported with ventricular assist devices (VADs, group II). Forty percent of the patients in each group died before transplantation. Of the 20 group I patients who underwent transplantation, all received inotropic drugs, and five also required IABPs. All 14 group II patients who underwent transplantation were bridged with VADs. No difference was found in age, sex, or cause of disease between the groups. Complications after transplantation were more common in group I. Fourteen group I patients (70%) and 14 group II patients (100%) were discharged from the hospital (p = 0.03). One year after transplantation, mean left ventricular ejection fraction by cardiac catheterization was 53% in group I (12 patients) and 72% in group II (11 patients; p = 0.0008). Although VAD support does not insure transplantation, it strongly favors transplantation survival in status I patients. These data further suggest an advantage of VAD support for long-term survival.

Actuarial Analysis↗

PubMed1992

The endodontist and the general dentist.

As the title suggests, most of this article has discussed the relationship between the general dentist and the endodontic specialist. In attempting to shed some light on this very intricate referral process, one should not lose sight of the fact that it is ultimately the dental patient needing the root canal treatment who should be the recipient of any improvement that develops in this referral process. General dentists have always, and, most probably, will always provide the great majority of root canal treatments done in the United States. Many factors, however, will, from time to time, cause the thoughtful general dentist to refer at least some cases to endodontic specialists. Patients have very little to say in this process; however, we must all realize that they place a great deal of trust in both the general dentist and the endodontist to work together to come to the best resolution of their endodontic problems. The primary concerns of most patients seem to fall into the areas of fear of the treatment and fear of the cost. Costs are driven by expenses, insurance tables, and market factors. Although it cannot be said that endodontic treatment is inexpensive, it can usually be stated that there is good value received for the treatment given. This is particularly true if the end result is a quality job done with long-term retention of the problem tooth. As to the patient's fear concerning pain, it is incumbent on both the generalist and the specialist to develop the skills necessary to render modern endodontic treatment in a pain-free manner. This is within the standard of care, and is something the patients should not only expect but, in fact, demand. The other concerns that patients have are quite standard in the profession. They are, primarily, the desire for pleasant surroundings, pleasant staff, confident doctors, convenient pay arrangements, understanding of the procedure, and a perception of value for time and money spent. Working together, the endodontic specialist and the general dentist should certainly be able to provide these wishes for all patients.

Attitude of Health Personnel↗

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↗

PubMed1991

Long-term sick-listing, medical rehabilitation and life quality change: a patient evaluation.

This evaluation of the health service at one of the hospitals of the National Insurance Board in Sweden is primarily based on the perspective of the patient. One interview group of 32 patients (I-group) made life quality ratings before-after their hospital stay. In responding to a postal questionnaire one year after discharge from hospital, another group of 93 former patients (Q-group) made parallel self-ratings. Due to prolonged sick-listing, the patients had been admitted to the hospital for rehabilitation/examination according to paragraph 2:11 in the general insurance law. The basis for their sick-listing was hereby critically reviewed. Within the framework of additional examinations (interview and structured general questions), more than 40% of the respondents stated that the hospital stay was mainly satisfying and a great majority appreciated the nursing care. However, the self-ratings showed that the patients did not ascribe any particularly great significance to the hospital stay. In the short term, it even seemed to have a certain negative impact on the life quality of the patients. No obvious positive bias seems to be built into the ratings. Thus, the assessment package applied may also work well in similar evaluative settings.

Adult↗

PubMed1992

Trends in spinal cord injury demographics and treatment outcomes between 1973 and 1986.

A study of the National Spinal Cord Injury Statistical Center database on 6,563 persons treated at Spinal Cord Injury Care Systems was conducted to detect demographic and treatment outcome trends over time. Data from the initial hospitalization and first two years postinjury were divided into four time periods based on injury year (1973 to 1977, 1978 to 1980, 1981 to 1983, 1984 to 1986). Between 1973 and 1986, mean age at injury increased, as did the percentage of nonwhites and the percentage of persons with quadriplegia, while the percentage of neurologically complete lesions decreased. There was an increase in long-term use of intermittent catheterization. Ventilator use during hospitalization also increased. Mean lengths of stay for acute care and rehabilitation decreased, although mean inflation-adjusted hospital charges increased. The percentage of persons rehospitalized during the second postinjury year decreased substantially. From 1973 to 1986, for persons admitted to the model system within 24 hours of injury, there was a 66% decrease in the risk of dying within the first two years postinjury. Overall, these data document changing demographics and treatment practices as well as an improved prognosis for persons with spinal cord injuries.

Adult↗

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↗

PubMed1978

Factor affecting the choice between two prepaid plans.

This study examines the factors affecting the choice between two comprehensive prepaid plans of medical care available to the staff of Stanford University. One is a Kaiser plan, offered since 1969. Under the other (Clinic plan for short), medical services are provided by a predominantly fee-for-service group practice and hospital services are covered by a standard Blue Cross hospital policy; the Clinic plan has been available since the 1950s. The Kaiser plan has only a token copayment for office and home visit while the Clinic plan has a 25 per cent coinsurance provision applying to all physician and outpatient ancillary services. It was found that the two major factors affecting choice were income and distance to the provider. The preference for the Kaiser plan increased as income decreased. Similarly, as distance from the Clinic increased and distance from a Kaiser facility decreased, the preference for the Kaiser plan increased. However, proximity to the provider was a more important factor for the higher-income Clinic plan subscribers. The data also show that the longer availability of the Clinic plan had a long-term effect on enrollment. A substantial proportion of long time Stanford employees who might have been expected to prefer the Kaiser plan stayed with the Clinic plan.

Attitude to Health↗