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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↗

PubMed1991

Risk stratification and outcome assessment of the adult cardiac surgical patient.

Comparisons between institutions are already occurring, and comparisons between individual providers may also become a reality. In spite of the negative views of such comparisons, they are likely to be mandated because of pressure from health care regulators, insurers, and patients. Despite awareness of the importance of demographic variables and concurrent medical problems in influencing outcome, valid comparisons are presently difficult to conduct in the open heart surgical population. Current methods of risk stratification each have limitations. A method for risk assessment based on multivariate analysis from a large group of patients that can be prospectively validated at multiple institutions would be valuable, not only for mortality rate comparisons, but also for patient counseling, research, and hospital management uses. Caution must be applied when using risk assessment in individual patients. Physicians need to be involved in the development of such severity stratifying systems, since inclusion of inappropriate or medically irrelevant data can influence the outcome of multivariate analyses. Ongoing research and evolution of scoring systems also need to occur since therapy changes over time. It is likely that models will need to be developed for application preoperatively, at ICU admission, and for the complex, long-term patient at 7 days or beyond, in order to fully inform medical decision-making.

Adult↗

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↗

PubMed1990

The advent of clinical standards for professional liability.

The development of clinically based written standards to reduce the frequency and severity of medical malpractice loss appears to be gaining in popularity among provider specialty groups and professional liability underwriters. To date, such standards have addressed problems in specialties such as obstetrics and anesthesia where dollar losses associated with malpractice claims have been high. Guidelines can be developed and used by providers on a purely voluntary basis or mandated on an involuntary basis by third parties such as malpractice insurance companies or legislators. Because the advent of risk-control standards is a relatively new phenomenon, formal scientific studies on the long-term benefits of such guidelines have not yet been published. However, it appears that sharp reductions of malpractice losses in specialties such as anesthesia have coincided with the implementation of formal written standards specifically designed for liability control. This has led some liability insurance carriers to decrease premiums associated with specialists following such standards. Many providers are understandably concerned about the potential use of written standards by plaintiff attorneys in medical malpractice suits. Although it is possible that such policies and guidelines could be admitted into evidence to show that a provider breached the legal duty or standard of care owed to a patient, it is uncertain whether these risk-control standards could ultimately pass the evidentiary rules of relevancy or materiality in a given lawsuit. It is clear, however, that the consensus-based process of creating clinical standards and guidelines specifically for controlling professional liability losses is itself a powerful and emerging standard for health care risk management programs.

Clinical Competence↗

PubMed1990

Health care policy issues in the drug abuser treatment field.

As we enter the 1990s drug abuse has once again become a major health concern, and for the first time the drug treatment field has had to address many of the policy, regulation, and planning issues resulting from cost inflation that have become commonplace in other parts of the health care field. To avoid serious errors and confusion, drug abuse health policies must recognize the very different needs of the public and private sectors. The public sector, where poor addicts receive drug treatment provided or purchased by the government, has long suffered from chronically inadequate funding. Although responses to several epidemics (heroin, crack, and AIDS) have produced periods of increased allocations for drug abuse treatment, more often than not long waiting lists at programs have rationed treatment to lower-income addicts seeking care. Low salary levels have limited the quality of public treatment services, and the absence of resources has hindered the development of programs that respond to new technical developments and drug abuse problems, such as the crack epidemic. Despite severe resource shortages, the public drug treatment system has sometimes used resources inefficiently, with little attention to appropriateness of admissions, lengths of stay, ambulatory treatment modalities, or varying levels of care. Public sector goals for the 1990s should include filling current shortages in drug treatment services, developing adequate long-term funding for treating addicts who lack third-party coverage, modernizing the treatment system, developing new patterns of practice that use existing resources more efficiently, and developing a plan for treating intravenous drug users infected with the AIDS virus. In the private sector, the advent of working- and middle-class demand for drug treatment in the 1970s and 1980s has produced a new drug treatment system that suffers from many of the policy problems common to the rest of health care. Drug abuse in the workplace has resulted in much wider coverage of substance abuse services by insurance companies and HMOs. The availability of third-party funds has spawned a for-profit chemical dependency treatment industry. The high cost of private residential treatment services has caused significant cost inflation. Cost-containment measures, which are a new phenomenon for this field and are inappropriate for the public sector, have led to the same confusion and debates that they have produced in other areas of health care.(ABSTRACT TRUNCATED AT 400 WORDS)

Acquired Immunodeficiency Syndrome↗

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↗

PubMed1991

Financial counseling for families of children with chronic disabilities.

A program to teach financial management skills to parents of children with chronic illnesses and disabilities was developed. To test the effectiveness of this program, a randomized, controlled prospective study was conducted of 115 families of children with spina bifida, 58 of whom received financial counseling while 57 served as controls. Significantly more frequent changes in behavior were found in the intervention group than in the control group at the end of the one-year study for 18 of the 68 variables, including such items as establishing records, using a budget, obtaining low-cost life insurance and taking appropriate tax deductions. Three-quarters of the families in the intervention group believe that the counseling program had had or would have a beneficial effect on the quality of their lives. Financial counseling may benefit families with chronically ill or disabled children.

Budgets↗

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↗

PubMed1990

Managed care and the discharge dilemma.

Efforts at cost containment in medicine and psychiatry are ubiquitous. The escalating costs of health care have led to a variety of initiatives to manage the use of expensive settings and treatments. Cost containment aims to be cost efficient. When it is applied to the treatment of the severely mentally ill, clinical and ethical dilemmas intensify. Access to health insurance is more restricted for the mentally ill (Sharfstein et al. 1984). The benefits that are available are rationed by "fourth party" case managers, independent operators who make money by selling "third party" insurance companies the services of reviewing ongoing care in such a way as to contain costs and conserve resources. Most often this involves pressure to develop discharge plans and to move patients from the expensive inpatient to the less expensive outpatient setting as soon as it is safe and feasible (Melnick and Lyter 1987). For some patients, however, as illustrated below, this proves to be a most formidable task.

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↗

PubMed1991

[Institutionalized elderly in Reykjavik in 1984. Their opinions of dental visits, need for dental service and possible changes in dental service and third party payments].

In 1984 an investigation was done among a random sample of 400 old-age pensioners, 67 yrs, and older, who were either inmates of old people's residential or nursing homes or long-term patients in geriatric departments at the hospitals in Reykjavík. A dentist asked all participants standardised questions, among which were: questions concerning dental visiting habits; opinion on the dental public health system; subjective estimation on own need for dental services; opinion on the services rendered by the dental profession; and refunds of dental fees by the public health system. During the last twelve month period only 16.6% had visited a dentist and 34% had not gone to a dentist for more than 20 years. Of those who had made use of dental services during the last 5-10 years, 79.6% said they were satisfied. Barely 75% considered themselves in need of dental services, and 67.6% claimed that they would not seek dental services more frequently if they were made available in the institution, or if free transportation were available to the dentist's office. Only 35.9% said that they would make use of free dental checkups, while 82.2% however were in favour of free health services for old age pensioners. For statistical analysis chi-square at 5% level was used, comparing the answers by sex, age, and institution. There was no statistically significant difference with the exception of difference between institutions with regard to a question of free dental services (0.005 less than p less than 0.01). This question however did not give a significant difference between the sexes or the two different age groups.

Aged↗

PubMed1991

Effect of oxygen therapy on increasing arterial oxygen tension in hypoxemic patients with stable chronic obstructive pulmonary disease while breathing ambient air.

Recertification for long-term oxygen therapy (LTOT) has been recommended for patients who are clinically unstable when home oxygen therapy is begun. Periods of observation for clinical stability have ranged from three weeks to three months in large multicenter clinical trials. There is concern, however, that an increase in arterial oxygen tension occurring after three months may be related to the beneficial effects of oxygen rather than to continued changes in clinical stability. In a review of 20 patients receiving transtracheal oxygen (TTO2) therapy, it was found that four (20 percent) did not qualify for oxygen therapy at the end of six months because the PaO2 breathing ambient air had increased to levels above 55 mm Hg. All patients were clinically stable at the time of insertion of the transtracheal catheter and all had been receiving nasal oxygen for at least seven months (mean, 25.8 months) before entering the study. A retrospective analysis of data published by Weitzenblum et al disclosed that four (25 percent) of 16 patients had a similar increase in PaO2 when reexamined after one year of oxygen therapy. All of the patients had been studied at least one year before oxygen therapy was initiated and each had three consecutive arterial blood gas measurements done monthly to ensure clinical stability. The increase in PaO2 to levels above 55 mm Hg observed in patients receiving TTO2 therapy was associated with a reduction in alveolar-arterial oxygen gradient; however, arterial oxygen desaturation with walking persisted. The specific mechanisms for improvement in PaO2 during oxygen therapy require further study. Any recommendation for recertification of LTOT must recognize that an increase in PaO2 after three months may be due to the beneficial effects of the oxygen therapy and does not provide prima facie justification for termination of therapy.

Aged↗

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↗